Suicide After Medical Error Highlights Importance of Support for Clinicians

Rebecca Hendren, for HealthLeaders Media , May 10, 2011

"We operate from a belief that no one intends for errors to happen or seeks to create errors," says Edmonson. "Instead we realize it is often a complex interaction between the culture, the systems, the processes, and the people in an organization. We respond by thanking the person who reported the error, seeking to comfort those involved, seeking the truth of the situation, rebuilding trust among the team, and finding solutions, both people and process based, to mitigate further risk."

THPHD draws a distinction between human error, at risk behaviors, and reckless behaviors when examining what went wrong and the reasons behind it. Edmonson says errors and all variances should be systematically addressed through just culture algorithms for consistency, completeness, categorizing, and actions to be taken post analysis.

"One of the most difficult tenets of a true just culture is to not focus on the outcome of the behavior, but rather seek to understand the personal decisions, system influence, and context in which the decision was made, which helps us to address the real issues," he says. "It is very possible that two people can commit the same error with very different outcomes, so we have to ask ourselves from a just culture perspective, is one more egregious than the other because of the outcome?"

In light of the Seattle story, this is a pertinent question to ask.

"Removing the outcome bias, the fear of reporting, and having leaders that clearly understand how to operate in the just culture and to support staff is the best path to a reporting of errors," adds Edmonson.

Rebecca Hendren is a senior managing editor at HCPro, Inc. in Danvers, MA. She edits and manages The Leaders' Lounge blog for nurse managers. Email her at
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7 comments on "Suicide After Medical Error Highlights Importance of Support for Clinicians"

Rudy (7/21/2012 at 9:17 PM)
unfortunately, the culture in nursing lets it happen. Doctors call with orders, lab calls with critical values, family members call with questions/problems/complaints, transportation needs to take bed 2 to xray NOW, and if you make any of them wait, they are going to report you/write you up/ file a complaint/ stand there and yell/ let the phone ring on and on and on. Meanwhile you are trying to decipher a doctor's handwriting, find out what the last calcium level was, what the potassium level is, and what the cardiac monitor is reading (because there has to be a reason the calcium chloride was ordered, was it for high potassium must check EKG) and as you are on the computer attempting to do this, bystanders think you are browsing the internet Suddenly the final distraction happens and a med error is made.

Rudy (7/21/2012 at 9:13 PM)
"unfortunately, we have no idea how the error occurred and how the hospital handled the situation" Yes we do. She administered 1.4 grams of calcium chloride [INVALID] instead of the correct dose of 140 milligrams, which contributed not only to the death of the 8-month-old, but also to her firing, and a state nursing commission investigation.

Steven D. Hobbs, Ph.D., R.N., BC (5/23/2011 at 1:36 AM)
My heart goes out for the child, the parents, the nurse, her family and the facility involved. The facility is most to blame here. Obviously they chose the low road response. How likely is any nurse at that facility to now report an error? What does it say about their "support of nursing?" An excellent example as to why EVERY R.N. needs their own independent malpractice insurance (although this will not save your job, it may save your home). I hope they are not a Magnet facility.




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