Nurses, Medical Errors, and the Culture of Blame

In June 2004, an article in the American Journal of Nursing reported the findings of a three-year study of the organizational culture, attitudes, and assignment of responsibility for patient safety in small, rural hospitals in nine Western states. The study found that most errors fall within the realm of nursing practice and that physicians, administrators, and nurses themselves tend to see patient safety as largely a nursing responsibility. Asked to identify which profession has primary responsibility for ensuring patient safety, 96 percent of the nurses and more than 90 percent of the physicians, administrators, and pharmacists assigned primary responsibility to nurses. Only 22 percent of the respondents believed that physicians, nurses, pharmacists, and administrators share responsibility for patient safety equally.

Unfortunately, however, nurses and physicians differed on the role of nurses in effecting change. Most of the nurses indicated that they had several responsibilities in reducing medical errors, including reporting them, educating themselves and colleagues, serving as role models, making recommendations for changes in procedure and policy, reviewing reported adverse patient-safety events, and participating in investigations. Only 8 percent of the physicians who responded to the survey identified nurses as members of the decisionmaking team.

Nurses have a genuine impact on patient safety. Studies have found a link between patient safety and RN staffing and an increased rate of error when the hospital nursing staff has a smaller proportion of RNs. These are worrisome findings in light of the severe national shortage of nurses. Part of the medical malpractice crisis, then, is the confusion in the health care system and how it affects the role of the nurse.

There is no confusion in the American Nurses Association's code of ethics. This document, first adopted in 1950 and revised in 2001 to reflect and embrace the role of today's nurse, consists of a set of planks that set out nurses' fundamental values and commitments. They also offer a starting point for understanding how nurses should be involved in thinking about medical error, and why nurses blame themselves for medical errors.

The first few planks are the most important. These planks state that the nurse's primary commitment is to the patient (plank 2), and that the nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient (plank 3). "Interpretive Statements" that accompany the code add that nurses are committed to the patient's health, well-being, and safety throughout the patient's life span, and in all settings in which health care needs are addressed. Further, the code directs that, as an advocate for the patient, "the nurse must take appropriate actions regarding any instances of incompetent, unethical, and illegal practice by any member of the health care team or health care system or any action on the part of others that places the rights or best interest of the patient in jeopardy." For nurses to function effectively in this role, they must be knowledgeable about the code of ethics, the standards of practice, relevant laws, and their own organization's policies and procedures.

Moreover, when the nurse is aware of inappropriate or questionable practice in the provision or denial of health care, concerns should be expressed to the person engaging in the questionable practice. Attention should be called to the possible detrimental effect upon the patient's well-being or best interests, as well as to the integrity of nursing practice. When factors in the health care delivery system or health care organization threaten the welfare of the patient, concerns should be directed to the responsible administrator. If indicated, the problem should be reported to an appropriate higher authority within the institution or agency, or to an appropriate external authority.

The interpretive statements for the third plank also remind nurses that they have a responsibility to implement and maintain the standards of professional nursing practice. They recommend that nurses "participate in planning, establishing, implementing, and evaluating review mechanisms designed to safeguard patients and nurses, such as peer review processes or committees, credentialing processes, quality improvement initiatives, and ethics committees." Nurse administrators must ensure that nurses have access to and...