PS 101 Lesson 2: Responding to Errors and Harm
When errors or unintended events occur, it is human nature to look for someone to blame. And yet, this approach does not undo the error or event, nor does it prevent its recurrence. As we saw in Lesson 1, errors and unintended events are typically the result of faulty systems — not faulty people. In addition, a blaming approach often leads to punitive action against the individual being blamed, compounding the terrible shame and guilt they are suffering, especially if someone has been hurt.

This lesson provides a brief discussion of blame and punishment — the most traditional responses to error and unintended adverse events — and outlines why they are not effective. The lesson also suggests a more productive approach to responding to error and unintended events.
Estimated Time of Completion: 30 minutes
Learning Objectives
After completing this lesson, you will be able to:
1. Describe why blaming and punishing individuals are not productive responses to error and unintended events.
2. Identify the reasons why people tend to blame and punish individuals after an adverse event.
3. Explain why systematic learning from error and unintended events is the best response to ensuring patient safety.
Contributors
Author(s):
Fran Griffin, RRT, MPA, Consultant, Fran Griffin & Associates LLC View Profile
Editor(s):
Laura Fink, Senior Managing Editor, Institute for Healthcare Improvement View Profile
Stephanie Garry Garfunkel, MA, Managing Editor, Institute for Healthcare Improvement View Profile
Reviewer(s):
Lucian Leape, MD, Adjunct Professor of Health Policy, Harvard School of Public Health View Profile
Requirements
You must be a registered IHI.org user to take this lesson.
You must achieve a minimum score of 75% to successfully complete this lesson.