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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 www.StrategiesForNurseManagers.com and manages The Leaders' Lounge blog for nurse managers. Email her at rhendren@hcpro.com.
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5 comments on "Suicide After Medical Error Highlights Importance of Support for Clinicians"


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.

stefani (5/20/2011 at 10:10 AM)
This is even more tragic when we know darn well that a physician causing the death of a patient results in some courtroom time, some hand slapping and then back to business as usual. Licenses are rarely revoked and even when they are, the physician simply pulls up stakes and moves to the next state.

Bill Gustafson (5/14/2011 at 4:50 PM)
What can be said about such a tragedy. Loss of life is always sad and I have never seen the perfect system that eliminates all risk. I have been in administration and now the medical equipment side. Devices, pharmaceuticals, services all have their inherent risk. I agree that somehow we must be responsible yet accept the errors and balance that with the good we do. Supporting those who are the front line in health care should be a given or you will loose those who care in favor of those who don't.