The recent case of a former nurse who was found guilty of negligent homicide after the death of a patient due to a medication error prompts the need to underscore the recommendations from To Err is Human: Building a Safer Health System. A core finding of To Err is Human is that medical errors are most often caused by failures in systems, processes, and conditions that lead people to make mistakes or do not prevent them. The report does not absolve individuals from accountability, but emphasizes that errors are typically the result of shortfalls in system safeguards against individual missteps. When an error occurs, the most effective way to prevent future errors is through systems-level changes that make it as simple as possible for individual health care workers to “do the right thing” and establish multiple protective mechanisms to prevent harm to patients even when an individual error might occur.

To Err is Human is one of the National Academy of Medicine’s (formerly the Institute of Medicine’s) best-known and most frequently cited reports, and its recommendations and findings serve as the cornerstone of the patient safety and quality movement throughout the nation. Patient safety and quality, and by association, health care safety and quality, can only perform in a reliable and continuously improving manner when clinicians feel safe and comfortable reporting errors. When errors are hidden, patient safety suffers, and we are concerned that this case will inhibit rather than promote the reporting of errors.

There is also concern from the health community about the impact that this case will have on the nation’s highly committed but also highly strained health care workforce, especially nurses. The nation’s health care workforce is already experiencing never-before-seen levels of burnout and stress, and many are leaving practice due to the extreme stressors of COVID-19. Improving and protecting patient safety is contingent upon the understanding that systems-level changes are what can and will improve health care and support our health care workforce.

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