I’ve been updating a chapter on the roots of patient injury for the fourth edition of Nursing Malpractice. I’ve been thinking about the reasons people don’t follow policies and procedures. Back in the 1980s when I ran a nursing hospital’s staff development department, I learned that if people did not have the knowledge, this was an educational problem and we were to educate. If they knew how to perform their jobs but chose not to, this was a management problem and their managers were to counsel and discipline. Now we think about this issue in expanded terms.

1. Safety standards are not monitored or enforced
People may not do their jobs correctly because there are no consequences if they don’t. Managers must be clear about the need to follow policies and procedures and the consequences of not doing so. Continual monitoring and education about the importance of patient safety sends an obvious message about the value of patient safety policies.

2. Lack of knowledge
Staff may be unaware of how to perform aspects of their job. They need training and competency checks. They may lack knowledge about how medical errors occur. Integration of patient safety information into the curriculum of schools of nursing helps to increase knowledge and skills.

3. Dysfunctional systems
Convoluted systems are sometimes created by providers or administrators who lack essential training in human factors and systems engineering, which may make it too hard to adhere to the practice. This invites workarounds because it becomes too difficult to follow the procedures.