Intended for healthcare professionals

Rapid response to:

Education And Debate

On error management: lessons from aviation

BMJ 2000; 320 doi: (Published 18 March 2000) Cite this as: BMJ 2000;320:781

Rapid Response:

Reducing Errors by Preventing Legal Sanctions for Error Reporting

I have read Helmreich's book "Culture at Work in Aviation and
Medicine," have several years experience in the operating room, and am
researching medication error reduction for my dissertation.

The error problems inherent with the OR include the inherent culture
that surgeons are trained under. Namely to reject comments made by nurses
and others who are attempting to report a problem, or worse yet to yell at
the reporting person as if to blame them (Helmreich, 1998). This should be
included in both the latent and existing error conditions.

Leadership should come in the form of collaboration rather than the
typical "captain of the ship" mentality so frequently found in the United

As is implied in Helmreich's book, a team approach should exist in
which all those in the OR work as equals, supporting and respecting each
others comments. With the impending nursing shortage, more collaboration
is needed and less abuse in the OR (Helmreich, 1998). Nevertheless other
medical error is related to legal sanctions imposed by licensing boards
and regulatory agencies.

A major barrier to medication administration errors (MAE) continues
to be he lack of state and national legal protections for individuals and
institutions (ISMP, 2000). During 1999, the United States Pharmacopeia
gathered valuable medication error data using an anonymous reporting
system. However, only 56 of 6000 hospitals participated due to fear of
repurcussions (USP, 2000). Until laws are in place to protect individuals
and institutions who report errors, they will continue, thus decreasing
the chance of eliminating the system failures. Of course, there would need
to be exceptions to these protections. For example in the case of
intentional harm or neglect, drug abuse, or when the patient was seriously
harmed. But many of the errors that are not reported have resulted in
little or no harm to patients. Yet nurses do not report due to the fear of
retaliation. Even with some institutions anonymous reporting systems, many
nurses do not trust that their job will not be affected by reporting. That
is why a nationally based voluntary reporting mechanism via encrypted
internet access by individuals is the best way to obtain error
information. In addition, laws should be in place to protect individuals
from discoverability unless there was serious injury, malicious intent or
drug abuse.


Helmreich, R. L., & Ashleigh, C. M. (1998). Culture at work in
aviation and medicine: National, organizational and professional
influences. Aldershot Hants, England: Ashgate Publishing Limited.

Institute for Safe Medication Practices [ISMP](2000). A discussion
paper on adverse event and error reporting in healthcare. Available on the
World Wide Web:

United States Pharmacopeia [USP](2000. Summary of the 1999
information submitted to medmarx: A national database for hospital
medication error reporting. Available on the World Wide Web:

Competing interests: No competing interests

27 April 2001
Tess M Pape
Alvin Community College