al., 1996). Like the general public, they perceive errors to be due to carelessness, inattention, indifference, or uninformed decisions. Requiring high standards of performance for nurses is both appropriate and desirable, but becomes counterproductive when it creates an expectation of perfection. Because they regard clinical perfection as a professional goal, nurses feel shame when they make an error (Leape, 1994), which in turn creates pressure to hide or cover up errors (Osborne et al., 1999; Wakefield et al., 1996) (see the example presented at the beginning of Chapter 1).

It is difficult to transform thinking associated with the blame and shame mentality (Banister et al., 1996; Manasse et al., 2002). In a study conducted to assess safety culture transformation over time at six VA medical centers, the first change noted was the realization that errors are the result of a systemic rather than an individual problem. Within a year, health care providers were reporting that they would not think less of coworkers who made errors. One of the last changes to occur was that providers did not think worse of themselves when an error occurred.¹ Such a transformation requires extensive education and training and support at all levels of the organization.

Unfortunately, regulatory boards and litigation practices reinforce the myth of clinical perfection, as illustrated by the two cases presented in Box 7-1.

These two cases (Cook et al., 2000; Grant, 1999; Knox, 2000; Schneider, 1999; Senders, 1999) illustrate a persisting focus on individuals rather than systems as the sources of error among licensing boards in medicine, nursing, and pharmacy; regulatory bodies, such as health departments; and sometimes the judicial system (Grant, 1999; Manasse et al., 2002). Malpractice litigation reinforces this perception. One result of this situation is that the consequences of litigation for the nurses involved in these and similar adverse events, in which nurses were fined, fired, sued, or otherwise punished (Serembus et al., 2001; Sexton, 1995), create serious disincentives to disclosure of errors or near misses on the part of nurses and other health professionals. The threat of legal liability is a strong barrier to voluntary reporting of errors (Schneider, 1999) and to the design of measures to prevent additional errors in the future.

The IOM report To Err Is Human speaks directly to these disincentives and identifies two steps HCOs can take to counteract them when designing