From the President's Desk

Too Err is Human

Tampering with medical records is about a larger issue: consequences of truth telling and accountability. The sister of an LPN who was sent to prison for tampering with medical records was quoted as saying, "This one woman’s whole life was shattered by one stupid record-keeping mistake. She’s going to be forced out of the profession she loves and she’s damn good at." Falsifying records is more than a record keeping mistake. It is a deliberate effort to deceive. Fueled by panic and fear, healthcare professionals risk their careers because of fear of consequences. Our healthcare system has punished people who report errors. For too long, nurses have been suspended or terminated for making errors. In one hospital with which I am familiar, the policy was to terminate a nurse after she reported three medication errors. The Pharmacy and Therapeutics Committee reviewed every medication error. One month a total of 6 medication errors were reported in this 650 bed hospital. The physician committee chair declared that he wanted to reduce the errors to zero. Neither the doctor nor the Vice President of Nursing recognized that the punitive policy of terminating nurses for reporting errors was encouraging nurses to hide their errors.

When we punish people for reporting errors, we drive reporting underground and not learn about the mistakes that are being made that affect our system. Fortunately, this is beginning to change in healthcare as the concept of a non-punitive environment takes hold.

What is the philosophy in your law firm about mistakes? Are employees disciplined or terminated for making errors? Are errors viewed as opportunities to review how your system functions, and as a stimulus for changing operations to improve efficiency? Did your employee make an error because instructions were unclear and inadequate training was provided? Did your associate make an error because she was working a 12 hour day? Was a critical document misfiled because you were representing two people with the same first and last name and do not have a way to differentiate between the two? Do your support staff feel comfortable enough to admit to making a mistake without fear of your reaction? The answers to these uncomfortable questions stimulate business owners to examine themselves and their systems. Remember, to err is human, to forgive is divine. To fix the system to improve it is the mark of an effective team.

For more information see:

Medication Errors video by Patricia Iyer

Pat Iyer discussing medical records tampering on television

Pat Iyer discussing medication errors on television