After reading "Medication errors: Ending the blame-game," (August 2004), I couldn't help but think of two experiences I've had in error reporting. The first was a medication error secondary to legibility and transcription. It passed through several systems before the actual error occurred. The manager was livid upon receiving the report and responded by yelling. The second experience involved a medication given twice to the same patient, by two separate nurses at shift change. The second manager responded differently, with words of support. She asked, "What can we do to prevent this from happening again?"

Incidents are rarely caused by the actions of one person. It's imperative that leaders use incident reporting to identify system flaws, not to penalize individuals. Reporting systems are established to examine the root cause of an error. An environment that encourages medication error reporting will lead to fewer errors.

System errors have devastating outcomes. According to an article in Nursing98, three Denver, Colo., nurses were charged with negligent homicide for the accidental death of an infant, caused by a medication error. During trial, 50 different failures in the system were identified. This example alone qualifies the significance of system flaws.

Experts offer the following advice, "To err may be human, but failure to share those errors, learn from them, and prevent them from happening again is unforgivable." As leaders, we must be committed to changing the blame culture that associates errors with negligence into a situation of learning. Staff must understand that incident reporting is meant to detect system faults, not to serve as a vehicle to deliver punishment. Errors are reduced by changing systems, not individuals. System flaws must be identified so that we may learn from our mistakes, not repeat them.

Bridgett Robbins, RN, BSN

Columbia, Mo.