Errors in Medicine: Punishment versus Learning Medical Adverse Events Revisited—Expanding the Frame
Open accessAbstract
Purpose of review: Despite healthcare workers’ best intentions, some patients will suffer harm and even death during their journey through the healthcare system. This represents a major challenge, and many solutions have been proposed during the last decades. How to reduce risk and use adverse events for improvement? Recent findings: The concept of safety culture must be acknowledged and understood for moving from blame to learning. Procedural protocols and reports are only parts of the solution, and this overview paints a broader picture, referring to recent research on the nature of adverse events. The potential harm from advice based on faulty evidence represents a serious risk. Summary: Focus must shift from an individual perspective to the system, promoting learning rather than punishment and disciplinary sanctions, and the recent opioid epidemic is an example of bad guidelines.
The claims and statistics of this paper haven’t been checked yet.
Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
The claims and statistics of this paper haven’t been checked yet.
Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
The medical malpractice system and state licensing boards can cause healthcare staff to be less willing to report medical errors due to the fear of adverse administrative consequences, suggesting the importance of creating a tolerant and safe working culture that emphasizes learning.
“However, they can also cause healthcare staff to be less willing to report medical errors due to the fear of adverse administrative consequences, suggesting the importance of creating a tolerant and safe working culture that emphasizes learning [257,258].”
From Toward Safer Diagnoses: A SEIPS-Based Narrative Review of Diagnostic Errors (2026) · cites this paper as [258]
Split into 2 atoms — 1 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.
Experimental — accuracy not yet measured
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
The self-check needs the paper’s full text.
Cites
No references could be resolved yet.
Research works printed but not linked: 29
- [1]Brattebø G Bergström J Neuhaus C. What's in a name? On the nuance of language in patient safety. Br J Anaesth 2019; 123: 534– 536. 31472923
- Murray JS Clifford J Larson S. Implementing just culture to improve patient safety. Mil Med 2022. usac115. 35587381 This article describes various aspects of how a just culture may be introduced in medicine.
- Cribb A O’Hara JK Waring J. Improving responses to safety incidents: we need to talk about safety. BMJ Qual Saf 2022; 31: 327– 330. PMC8938662 35058331 The dilemmas and uncertainties in relation to justice, seen from both the patients and healthcare providers are discussed in this important article, ending with some pertinent questions to be addressed.
- [4]Braithwaite J Clay-Williams R Nugus P Plumb J. Hollnagel E Braithwaite J Wears RL. Health care as a complex adaptive system. Resilient healthcare. Boca Raton, Florida: US: CRC Press; 2013. 57– 76.
- [5]Suclupe S, Kitchin J, Sivalingam R, McCulloch P. Evaluating patient identification practices during intrahospital transfers: a human factors approach. J Patient Saf 2022 [Epub ahead of print]. 36170519
- [6]Østergaard D Madsen MD Ersbøll AK. Patient safety culture and associated factors in secondary healthcare of the Capital Region of Denmark: influence of specialty, healthcare profession and gender. BMJ Open Qual 2022; 11: e001908. PMC9615985 36288806
- [8]Aljabari S Kadhim Z. Common barriers to reporting medical errors. Sci World J 2021; 2021: 6494889. PMC8211515 34220366
- [9]Lee SK Rowe BH Flood CM Mahl SK. Canada's system of liability coverage in the event of medical harm: is it time for no-fault reform? Healthc Policy 2021; 17: 30– 41. 34543174 PMC8437250
- Preckel B Staender S Arnal D. Ten years of the Helsinki Declaration on patient safety in anaesthesiology: an expert opinion on peri-operative safety aspects. Eur J Anaesthesiol 2020; 37: 521– 610. 32487963 In this report, published at the 10th anniversary of the Helsinki Declaration on Patient Safety in Anaesthesiology, experts in their fields addressed their topics and what needs to be done in the upcoming years to improve patient safety in anaesthesiology.
- [11]Eng DM Schweikart SJ. Why accountability sharing in healthcare organizational cultures means patients are probably safer. AMA J Ethics 2020; 22: E779– E783. 33009774
- [12]Schein EH. Organisational culture and leadership. Hoboken, NJ: John Wiley & Sons; 2010.
- [13]Flin R Burns C Mearns K Yule S. Measuring safety climate in healthcare. Qual Saf Healthcare 2006; 15: 109– 115. PMC2464831 16585110
- [14]Waterson P Carman EM Manser T Hammer A. Hospital survey on patient safety culture (HSPSC): a systematic review of the psychometric properties of 62 international studies. BMJ Open 2019; 9: e026896. PMC6731893 31488465
- [15]Veazie S Peterson K Bourne D. Implementing High-Reliability Organization principles into practice: a rapid evidence review. J Patient Saf 2022; 18: e320– e328. 32910041
- [16]Rotteau L Goldman J Shojania KG. Striving for high reliability in healthcare: a qualitative study of the implementation of a hospital safety programme. BMJ Qual Saf 2022; 0: 1– 11. 35649697
- [18]Fencl JL Willoughby C Jackson K. Just culture: the foundation of staff safety in the perioperative environment. AORN J 2021; 113: 329– 336. 33788231
- [19]Banham-Hall E Stevens S. Hindsight bias critically impacts on clinicians’ assessment of care quality in retrospective case note review. Clin Med (Lond) 2019; 19: 16– 21. 30651239 PMC6399623
- [20]Patil N Manwani R Vyas V. Resilience of healthcare professionals involved in anesthesia practice: a cross-sectional questionnaire based pilot study. J Anaesthesiol Clin Pharmacol 2022; 38: 191– 195. 36171948 PMC9511864
- Verhagen MJ de Vos MS Sujan M Hamming JF. The problem with making Safety-II work in healthcare. BMJ Qual Saf 2022; 31: 402– 408. 35304422 This article is a thorough discussion of the challenges in making Safety-II work in healthcare.
- [22]Chuang YT Ginsburg L Berta WB. Learning from preventable adverse events in healthcare organizations: development of a multilevel model of learning and propositions. Healthcare Manage Rev 2007; 32: 330– 340. 18075442
- [24]Kok J Leistikow I Bal R. Patient and family engagement in incident investigations: exploring hospital manager and incident investigators’ experiences and challenges. J Health Serv Res Policy 2018; 23: 252– 261. 30027771 PMC6187500
- Wiig S Haraldseid-Driftland C Tvete Zachrisen R. Next of kin involvement in regulatory investigations of adverse events that caused patient death: a process evaluation (Part I - The next of kin's perspective). J Patient Saf 2021; 17: e1713– 1718. 31651540 PMC8612916 This study describes the experience from involving relatives in the investigation of very serious adverse events.
- [26]Stanley TH. The history and development of the fentanyl series. J Pain Symptom Managem 1992; 7: (3 Suppl): S3– S7. 1517629
- [27]Chow R. Purdue Pharma and OxyContin: a commercial success but public health disaster. Harvard Public Health Review 2019; 25: https://www.jstor.org/stable/45345199. [Accessed 27 October 2022].
- [28]Kolodny A. How FDA failures contributed to the opioid crisis. AMA J Ethics 2020; 22: E743– 750. 32880367
- [29]Van Zee A. The promotion and marketing of OxyContin: commercial triumph, public health tragedy. Am J Public Health 2009; 99: 221– 227. 18799767 PMC2622774
- The Lancet. Managing the opioid crisis in North America and beyond. Lancet 2022; 399: 495. 35122752 This editorial addresses the grim and lethal overdose epidemic in America in the wake of the OxyContin scandal.
- [32]Lundstrom K-J Drevin L Carlsson S. Nationwide population based study of infections after transrectal ultrasound guided prostate biopsy. J Urol 2014; 192: 1116– 1122. 24813343
- Baron RJ Lynch TJ Rand K. Lessons from the choosing wisely campaign's 10 years of addressing overuse in healthcare. JAMA Health Forum 2022; 3: e221629. 36219019 An important presentation of what can be learned after a decade of the choosing wisely campaign.
Cited by
Sorted by citations
Toward Safer Diagnoses: A SEIPS-Based Narrative Review of Diagnostic Errors
Yen, C., Epling, J. W., Rockwell, M., & Vaughn-Cooke, M. (2026) · Diagnostics · doi:10.3390/diagnostics16020347 · Cited by 6 · see citing works
- Authors
- Brattebø, G., & Flaatten, H. K.
- Affiliations
- Haukeland University Hospital (NO)
- Corresponding author
- Brattebø, Guttorm
- Venue
- Current Opinion in Anaesthesiology
- Published
- 2023-01-23
- Volume
- 36
- Issue
- 2
- Pages
- 240-245
- ISSN
- 0952-7907 (ISSN-L)
- 1473-6500
- PMC
- PMC9973433
- OpenAlex
- W4318165520
- Cited by
- 12
- References
- 0
- Citations by year
- 2026: 5 · 2025: 4 · 2024: 2 · 2023: 1
- FWCI
- 4.05
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- Locations
- Current Opinion in Anaesthesiology (publishedVersion, cc-by-nc-nd)
- PubMed Central (publishedVersion, cc-by-nc-nd)
- PubMed (publishedVersion)
- NORA - Norwegian Open Research Archives (submittedVersion, cc-by-nc-nd)
- Topics
- Health Sciences › Health Professions › Emergency Medical Services › Patient Safety and Medication Errors
- Health Sciences › Health Professions › Pharmacy › Medical Malpractice and Liability Issues
- Health Sciences › Medicine › Family Practice › Clinical Reasoning and Diagnostic Skills
- Keywords
- medical errors, adverse events, patient safety, safety culture, disciplinary sanctions, evidence-based practice, opioid epidemic, clinical guidelines, harm reduction
- MeSH terms
- Delivery of Health Care, Humans, Learning, Punishment, Safety Management, Medical Errors
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
Are you an author, or do you see a problem with this page? Request a review
