A new article in NEJM:
“In conclusion, harm to patients resulting from medical care was common in North Carolina, and the rate of harm did not appear to decrease significantly during a 6-year period ending in December 2007, despite substantial national attention and allocation of resources to improve the safety of care. Since North Carolina has been a leader in efforts to improve safety, a lack of improvement in this state suggests that further improvement is also needed at the national level. Although the absence of large-scale improvement is a cause for concern, it is not evidence that current efforts to improve safety are futile. On the contrary, data have shown that focused efforts to reduce discrete harms, such as nosocomial infections10,36 and surgical complications,37 can significantly improve safety. However, achieving transformational improvements in the safety of health care will require further study of which patient-safety efforts are truly effective across settings and a refocusing of resources, regulation, and improvement initiatives to successfully implement proven interventions.”

Read the following from Google News this week. These are all being called “human error” although many seem like they are predictable human factor issues that should be built into safety systems. These involve police, pilots and NASA.

Police:
A woman reported calling 911 three times after being punched in the face by her brother. The call was sent to two different country police offers who were dealing with another violent situation nearby and an Alzheimer’s woman who was missing. The call center logged the complaint by woman who was punched, but the officers did not follow through with procedures. click read more below Read the rest of this entry »

In a just and high safety culture, failures are looked at in a systems approach rather than via the blame the individual approach. In a resilient organization that is consistently monitoring its failures and potential for failures, the most likely statement would be: There was a medication error in the PACU. The processes that led to the failure would be reviewed and a prevention plan would be developed with the assistance of the nurse who was at the sharp end of the failure.
The statement about the 5 rights is not likely to be heard as this also implies only individual accountability. For more information about weaknesses in reliance on the 5 rights framework, read this from the ISMP:

Q: Won’t medication errors be prevented if nurses just follow the “Five Rights?”
A: Many nurses during their training have learned about the “five rights” of medication use: the right patient, drug, time, dose and route.

•“Nurses’ rights regarding safe medication administration” ISMP Medication Safety Alert!® Nurse Advise-ERR July 2007
•The five rights: A destination without a map ISMP Medication Safety Alert!® Jan. 25, 2007
•“The five rights cannot stand alone” ISMP Medication Safety Alert!® Nurse Advise-ERR November 2004
•The “five rights” ISMP Medication Safety Alert!® April 7, 1999
ISMP report.