[NRSKarenRN]

Commentary: No Shame in Blame (Sometimes)

Leaders love to use lines like, "Medical errors are the result of process breakdown, not people breakdown." But how do you tell that to the millions of people who suffer medical errors each year?

Molly Rowe, for HealthLeaders Media February 8, 2008

[oramar]

I am not exactly sure what this person wants. How exactly do they want people to be punsihed? Very vague if you ask me. Take for instance Denis Quaid's twins. That exact same accident happened before. No warnings were issued by the goverment, the pharmaceutical company did not pull the vials, no steps were by taken by institutions to keep MED TECHs from putting wrong meds in drawer. So some nurse at the end of the line is the one that makes the actual mistake so what do you do boil the nurse in oil?

[Jolie]

I don't think this writer understands that identifying systems errors, which almost always come into play in medical mistakes, is not the same thing as absolving the individuals involved in the error, especially the "end user" who invariably gets the blame for the entire mess.

I think everyone would agree that the nurses who administered over-doses of heparin to Dennis Quaids babies made an error in checking the vials of medication. But it is vitally important that the systems errors that led up to the point of medication administration (similar labelling, dangerous drugs available in floor stock, not isolated from routine meds, stocking of Pyxis by unlicensed personnel, etc) be called to attention and addressed. Doing so does not absolve the nurses of their responsibilities, as this writer seems to imply.