Blame-free work environment

nurseprnRN, BSN, RN · Feb 17, 2014

"Blame-free" has such a seductive sound to it and is so very appealing to the high self-esteem crowd. But "consequences-free" is not the way life is. Nobody gets a free pass from consequences of "errors that will get you fired," except maybe the very cute niece of the chairman of the board, and even then I wouldn't bet on it.

Perhaps you could clarify?

JerseyGirl2010 · Feb 17, 2014

In my nurse management/issues class i read/heard things like "blame free environment" and "non-punative environment" and didn't fully understand how that would work in the hospitals. I know where I work if you make a mistake you get called on it and the supervisor or manager will sit down and remediate the problem- keep in mind I am talking about the telemetry monitoring department, where I work. But i'm wondering where the lines are drawn in the nursing world...i assume there are minor mistakes and then there are major mistakes....who decides what? And how the does the ''non-punative" system work? Even in my department we get written up for things like excessive tardiness and such.....

nurseprnRN, BSN, RN · Feb 17, 2014

The word is "punitive," and it is the most serious if it involves an actual crime (like theft, drug abuse, falsifying documentation, fraud, and the like-- the stuff you see on your state nursing association newsletter about the license restrictions and revocations for the past few months). However, you can lose a job if you show a pattern of careless errors which are not remediated despite repeated counseling.

Personally, I think the terms "blame-free" or "nonpunitive" are made up in management seminars to make people think they are being better managers, but have very, very little place in the world of actual patient care. Not no place, but not a blanket amnesty for every error, every time.

If an error is the result of a systems failure, they should recognize that and deal with it appropriately, such as, oh, the vials for two different meds have nearly-identical labels, or two different concentrations are kept in the same drawer (1mg/cc and 100mg/cc, for example). Yes, the nurse is responsible for reading the actual labels, so a med error with these would be a nursing error. So in the Utopian Nonpunitive Hospital, errors like this by 2 different nurses would be freely reported because they had no expectation of being punished, re-educated, or whatever, and the system failure would be identified and addressed. I would hope they'd pick it up after one, but you never know. Then if similar problems reoccur, the idea is that nurses might feel more likely to self-report in an attempt to make the system safer for all.

However in a famous case several years ago, a teenager in a L&D area died because a nurse put the totally wrong medication in her epidural pump, an antibiotic, I believe. There was a great hue and cry that she was overworked and the error wasn't her fault, but I strongly disagree. This wasn't a systems failure: the bag was properly prepared by the pharmacy, properly delivered, and properly/clearly labeled, and she plugged it into the wrong catheter, which took some doing. The 5 (or 6 or whatever) rights still apply. I don't believe in a blame/consequences/punishment-free system when it comes to that. At very least she should be restricted and reeducated before resuming full practice, and that's if they don't prosecute her for gross malpractice, or whatever they call it these days.

loriangel14, RN · Feb 17, 2014

If an error is the result of a systems failure, they should recognize that and deal with it appropriately, such as, oh, the vials for two different meds have nearly-identical labels, or two different concentrations are kept in the same drawer (1mg/cc and 100mg/cc, for example). Yes, the nurse is responsible for reading the actual labels, so a med error with these would be a nursing error. So in the Utopian Nonpunitive Hospital, errors like this by 2 different nurses would be freely reported because they had no expectation of being punished, re-educated, or whatever, and the system failure would be identified and addressed. I would hope they'd pick it up after one, but you never know. Then if similar problems reoccur, the idea is that nurses might feel more likely to self-report in an attempt to make the system safer for all.

This is how it works in my workplace. We don't get disciplined for errors. We can report ourselves or others. Unless you did something that was a crime or intentional you don't get punished. Error reporting helps management track patterns and if something is happening a lot then some education is provided to everyone to prevent the problem. I have never even been spoken to for an error.Part of the theory is that if we are afraid to admit a mistake then people will try to cover them up.

I am shocked at the number of times that I have read on here that nurses have been fired for ONE mistake. Especially nurses that have no previous history of any errors.

dudette10, MSN, RN · Feb 18, 2014

I have made two med errors that I self-reported and wrote my own incident report on. There was one policy "error" that another nurse caught, and an incident report was filed. I was counseled for all three, and I took responsibility for the med errors. They were not system errors; they were totally my errors. I knew what I had done wrong, and I've taken steps in my own practice to prevent it from happening again. However, for the third, I knew the policy better than the nurse who reported my policy "error," and during counseling, I defended myself. I had not violated policy, and my boss agreed with me. In fact, if I had done what the other nurse claimed I should have done, I WOULD have violated policy. Now, the proper policy is becoming common knowledge throughout the hospital, and I've actually had nurses say to me, "Oh, it's a new policy." I just chuckle because its always been there, but no one really knew about it until I had an IR filed about my supposed error.

As GrnTea stated, it would not help patient safety if there was a completely blame-free environment. If those two med errors I made occurred again, especially in the exact same fashion that the first two occurred in a short period of time, I would expect progressive discipline to be started on me. I'm a big girl, and it's my responsibility to learn from my mistakes and move forward to not do them again.

As for the third error, facts presented made the report moot. A good work environment also allows for a nurse to present her case and have the facts reviewed.

I work in a supportive environment where the counseling and discipline policies are well-known, so no one would be blind-sided by it. I do feel for those nurses who have actions taken against them that do not match discipline policy or seem excessive for the error. There are workplaces like that, and it is very sad and counterproductive to improving an individual nurse's practice.

While a blame-free environment should not be the goal, a balance in a supportive work environment should be carefully created by management, much like it is in my workplace. A balance between patient safety and allowing a nurse to make improvements in her practice should an error occur.