Criminal cases undermine efforts to improve safety

Every time a health care provider hears about another one being dragged off to jail for making a medical error, the risk management community’s efforts to improve the culture of safety loses ground, says Grena Porto, RN, ARM, DFASHRM, senior director of clinical operations at VHA Inc. in Berwyn, PA, and past president of the American Society for Healthcare Risk Management.

"I go around preaching full disclosure and admitting your mistakes in a nonpunitive environment, but people tell me we’ve got all these bureaucrats out there trying to throw people in prison for making mistakes," she says. "You know, it’s a great point and not one for which I have an answer. Clearly, the prosecutors are not on the same page as the rest of us."

Porto notes that risk managers have tried for years to improve patient safety by instituting systems in which health care providers can report their own mistakes without fear of heavy-handed retribution. That message has always been a hard sell, and to a large extent, people have to just trust you and see over time that people are not punished unfairly for reporting their mistakes. Slowly but surely, the message has been getting across.

"And then the local prosecutor comes in and arrests somebody in the hospital," Porto says. "That just paralyzes people. When you’re talking about actually charging someone with murder with putting them in prison, you’re talking about people’s very survival. That terrifies them and they decide they’re better off hoping nobody ever discovers the mistake."