Nonpunitive culture helps prevent drug errors

If you grabbed the wrong medication for just a moment before catching your error, would you complete a detailed incident report? What if the near miss would have been life-threatening for your patient?

Although many ED nurses are often reluctant to report errors, this practice is dangerous for patients, says Hedy Cohen, RN, BSN, MS, vice president for the Huntingdon Valley, PA-based Institute for Safe Medication Practices (ISMP). "ED nurses believed there would be negative consequences in reporting of errors — and with good reason," she says. "When a nurse reported their error, they were often written up or had other punitive action taken against them."

There is a trend toward encouraging staff to report errors without fear of reprisal, says Cohen. "The hospital can’t improve the system without having the pertinent information, and they can’t get the information without the reports from frontline practitioners," she says.

When the ED at St. Francis Hospital and Health Centers in Indianapolis switched to a nonpunitive medication event reporting system, nurses were at first reluctant to report errors. "The goal was to look at the process involved instead of the person who made the mistake, so you are not setting up others for failure as well," says Caroline Fisher, RN, manager of the ED.

During several inservices, staff were told very clearly that there would be no retribution, punishment, or "write-ups" for reporting these items, says Fisher. Subsequently, the number of nurses reporting errors has since increased dramatically. "In the past, nurses would do everything they could to get out of completing a medication event or incident report," she says. "Now they are much more willing to do it."

To maximize the benefits of a nonpunitive culture, take the following steps:

  • Ask the staff to report all errors, near misses, and dangerous conditions.

Reporting of near misses and dangerous conditions is extremely important because you can be proactive and prevent future errors from reaching patients, says Cohen. "You only need one incident report to know that if it happened once, it can happen again," she says. "You don’t need to wait until it happens 10 times before you act."

The importance of reporting even minor errors, such as grabbing the wrong medication, was underscored to staff, says Fisher. "That was drilled into the education. Staff were made aware that we want them to report any tiny thing that, in the past, they would not have reported. They have been very good about that."

Most of the time, the nurses are reporting on their own errors, such as when a physician asks if they gave intravenous morphine, and the nurse realizes she gave it intramuscularly, says Fisher. "When you realize that you are headed down the hallway with morphine when you were supposed to get [meperidine], it’s important to find out why that happened. Was somebody talking to you at the automated dispensing machine, was the wrong medication drawer open, was it labeled so you couldn’t read it?"

  • Call the form a "system improvement report" instead of an incident or error report.

"That sends the message that the goal is to improve patient safety and not to penalize the individual practitioner who committed the error," Cohen says.

  • Investigate every report.

Every event report made by nurses at St. Francis is reviewed and investigated by both Fisher and the interdisciplinary MEDS team. The downside is that the system is anonymous, so the errors are harder to investigate, says Fisher. "Since the practitioner’s name never goes on the form, it makes it a little tricky."

If Fisher needs more information about a report, she asks the ED’s patient care representative or charge nurse to determine contributing factors. "Caregivers find that less threatening than having me ask them, so they are more willing to provide additional details related to the event," she explains.

A possible solution would be to leave an optional space for the reporter’s name on the forms, says Fisher. "You would hope that it would get to the point where they wouldn’t be afraid to sign it, but the form currently has no place for them to sign, and they don’t."

  • Make changes based on incident reporting.

Near-miss reports on nurses grabbing the wrong medication revealed that the automated dispensing cabinet drawer allowed access to multiple medication bins, so the ED purchased a Pyxis MedStation 2000 (Cardinal Health, San Diego), an automated cabinet with drawers that only allow access to the specific drug to be administered, reports Fisher. (For contact information, see resources, below.)

  • Encourage nurses to provide safety solutions.

On reporting forms, include a space for the nurse to include recommendations for system changes to prevent errors from reoccurring, suggests Cohen. "Nurses are great problem solvers," she says.

Many solutions actually may be low or no cost, such as prohibiting verbal orders except in emergency situations and sterile conditions when the physician may be gloved and can’t write an order, adds Cohen. "This can prevent dosing errors, yet costs nothing."


For more information on nonpunitive reporting systems, contact:

  • Hedy Cohen, RN, BSN, MS, Vice President, Institute for Safe Medication Practices, 1800 Byberry Road, Suite 810, Huntingdon Valley, PA 19006. Telephone: (215) 947-7797. Fax: (215) 914-1492. E-mail:
  • Caroline Fisher, RN, Manager Emergency Department, St. Francis Hospital and Health Centers, 8111 S. Emerson Ave., Indianapolis, IN, 46237. Telephone: (317) 865-5440. Fax: (317) 865-5440. E-mail:

For more information on the Pyxis MedStation 2000, contact:

  • Cardinal Health/Pyxis Products, 3750 Torrey View Court, San Diego, CA 92130. Telephone: (800) 367-9947 or (858) 480-6000. Web: E-mail: