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Would you tell a patient about a medication error you made, even if it caused no harm to the patient?

For example, what if you gave your patient a normal dose of acetaminophen instead of aspirin? For some reason, both bottles were in the patient’s drug drawer, and you grabbed the wrong one. Your patient had no drug allergies or drug interactions. No harm was done, so you might think, “Why tell and risk upsetting this patient? Why tell my supervisor and risk looking careless to her?”

According to the ANA Code of Ethics for Nurses (available online at nursingworld.org), nurses have an ethical responsibility to report nursing practice errors to their supervisors, as per their facilities’ guidelines, and “to assure responsible disclosure of errors to patients.” This goes for any error, even those resulting in no damage or distress to the patient.

“Clinicians’ fears of lawsuits and their self-perception of incompetence could be dispelled by organizational cultures emphasizing safety rather than blame,” wrote Zane Robinson Wolf, RN, PhD, FAAN, and Ronda G. Hughes, RN, PhD, MHS, FAAN, in the chapter “Error Reporting and Disclosure” in “Patient Safety and Quality: An Evidence-Based Handbook for Nurses.” (The handbook is available online at www.ahrq.gov/qual/nurseshdbk/#toolsforquality.)

In a hospital where safety is emphasized, nurses can report all medication errors without fear of punishment. Bringing errors into the open so steps may be taken to prevent recurrences helps ensure patient safety. Errors are not simply individuals making mistakes, they are likely symptoms of a systemwide safety problem.

In the hypothetical situation with the aspirin/acetaminophen mix-up, it’s crucial to consider why the mistake was made. Are the two drugs in look-alike containers? Does the hospital need a new protocol for checking medications before and after they are put into drug cart drawers? It caused no harm this time, but next time the result might not be so innocuous.

Healthcare systems have much to gain by creating an environment in which staff members are not afraid to report errors, no matter how big or small. Wolf and Hughes conclude, “Reporting errors that result in patient harm as well as seemingly trivial errors and near misses has the potential to strengthen processes of care and improve the quality of care afforded patients.”

Donna Novak, RN, MSN, CRNP, is Director, Nursing Communications & Initiatives for Nursing Spectrum.

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