Too many health systems take a punitive approach to medical errors, thus failing to address the true causes of the problem, which tend to be a combination of human and systemwide errors, according to Judy Smetzer, RN, BSN, the vice president of the Institute for Safe Medication Practices (ISMP).
Instead, Ms. Smetzer urged organizations to adopt a “Just Culture,” which accepts that human errors will occur and sets out to design systems to minimize such errors. She discussed the