Mistakes happen. But in medicine, errors can have serious consequences, and they must be addressed when they happen. The challenge is to respond in a way that not only holds people accountable for their actions but also provides a supportive environment in which they can discuss and learn from mistakes.
The right response depends on the type of error. Many errors happen not because an employee is incompetent or uncaring but because processes are flawed and lead to making mistakes.
Here are four common types of errors and how best to respond to each:
"I gave the wrong vaccine because I misread a label."
|Consolation/correction||"Goodness, you made a mistake. How are you feeling? How can this process be improved?"|
|Negligent behavior||"I gave the wrong vaccine because I forgot to read a label."||Counseling/training||"To keep our patients safe, it is important to learn and follow the processes that we have put into place. Please let me know if you have any difficulty with maintaining these processes. How can this process be improved?"|
"I gave the wrong vaccine because I didn't bother to look at the orders."
|Punishment||"This is a written warning."|
"I gave the wrong vaccine because I chose to ignore the vaccination process."
|Punishment||Depends on the severity of behavior|
Table adapted from Marx D. Patient Safety and the "Just Culture": A Primer for Health Care Executives. New York, NY: Columbia University; 2001.
Adapted from “Addressing Ambulatory Patient Safety in Your Practice."
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