If nurses were careful enough, could we provideerror-free care? If that were the case, we should beable to significantly reduce errors by identifying the

nurse and punishing that nurse for “his” or “her” mistake.The negative consequences for the individual nursecould extend beyond the current place of employment,especially if the mistake was also reported to the statelicensing board. If this punitive model was effective, out-comes should include enhanced diligence by this nurseand other nurses and decreased risk of errors, withpatients assured of safer care.

However, as the 21st century began, nurses and otherswere realizing that nonpunitive environments are criticalin keeping patients safe and in improving outcomes.

Nursing employers and educators began stressing theneed to evaluate and improve systems as the effective wayto protect patients. To do this, the strategy of blamingindividuals had to stop.

At the same time, an opposite trend emerged, notfrom within nursing or health care but from the lawenforcement community. In spite of the lack of intent todo any kind of harm, some nurses and other health careworkers were not only being blamed for errors thatoccurred in the workplace but occasionally criminallycharged.

“Bad” patient outcomes are part of a health carecareer. Many nurses work with people who are suffering,sick, and fragile, many of whom will not get well.

The Criminalization of Mistakes in NursingNayna C. Philipsen, JDABSTRACTRecent studies and policies on safety and error reduction in health care contrast sharply with the punitive model of law enforcement. The advanced practice registered nurse, as a professional and as a stakeholder, can be an effective advocate against movement by stateprosecutors to treat health care errors as crimes. This is important in promoting patient safety and the general welfare of citizens, as well as protecting justice for health care professionals.

Keywords: criminalization of error, culture of safety, medical errors, nurse practitioner malpractice, patient safety, system performance© 2011 American College of Nurse Practitioners

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This CE learning activity is designed to augment the knowledge, skills, and attitudes of nurse practitioners and assist in their understandingof factors influencing the criminalization of nursing errors. At the conclusion of this activity, the participant will be able to:A. Evaluate elements of law for malpractice and crime as applied to mistakes in nursing practiceB. Describe the impact of criminalization in reducing mistakesC. Identify strategies to promote a culture of safety for patientsThe author, reviewers, editors, nurse planners, and pilot testers all report no financial relationships that would pose a conflict of interest.The author does not present any off-label or non-FDA-approved recommendations for treatment.There is no implied endorsement by NPA or ANCC of any commercial products mentioned in the article.

Readers may receive the free 1.0 CE credit by reading the article and answering each question online at www.npjournal.org, or they may mail the test answers and evaluation, along with aprocessing fee check for $10 made out to Elsevier, to PO Box 540, Ellicott City, MD 21041-0540. Required minimum passing score is 70%.

This educational activity is provided by Nurse Practitioner Alternatives™.

NPA™ is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

Nayna C. Philipsen, JD, PhD, RN, CFE, FACCE, is a professor, director of program development, and legal assistant to the dean atCoppin State University School of Nursing in Baltimore, MD. She has experience working for the Office of the Public Defender inDistrict Court in Maryland and has been admitted to the Bar in Maryland, the District of Columbia, the US District Court, andthe US Supreme Court. She can be reached at nphilipsen@coppin.edu. In compliance with national ethical guidelines, the authorreports no relationships with business or industry that would pose a conflict of interest.

Continuing Education

720 The Journal for Nurse Practitioners - JNP Volume 7, Issue 9, October 2011

Furthermore, because of the nature of our work, a singledecision or mistake can have life or death consequences.

What if these mistakes were a crime? Are there peersamong us who might choose not to be a nurse in thatworld? Any trend toward criminal prosecution of healthcare workers who make a mis-take in the practice of theirprofession should concern us,both for its impact on the safetyof care and on the future avail-ability of caregivers.

This article summarizesrecent studies and policies onsafety and error reduction inhealth care and contrasts thatwith what has been happeningin law enforcement. It also out-lines for the nurse and theadvanced practice registered nurse (APRN) how we canadvocate to improve patient safety and the general wel-fare of our citizens while protecting the integrity of ourprofession. While our focus is nurses and nursing, this isan important issue for any profession that is responsiblefor vulnerable populations, and the principles of safetyare the same.

WHAT IS A MISTAKE?According to the Merriam-Webster Dictionary, a mistakeis “a wrong judgment: misunderstanding, a wrong actionor statement proceeding from faulty judgment, inade-quate knowledge, or inattention.”1 We understand that amistake is an error, something that we did not mean todo and that we would not have done if we had correctlyunderstood all of the facts. At the time of the error, weusually thought that we were being careful and weredoing the right thing. Reasonable people can and domake mistakes.

Of course, the risk of making an error is greater if weare not being careful. If a person’s action is so carelessthat he fails to act the way a “reasonable” person wouldact under the circumstances and harms someone else as aresult, that is legal negligence.2 Nurses and other healthcare providers generally know that if this happens in thepractice of their profession, the “damaged” patient couldsue them for the monetary value of those damages. Weusually refer to that as “malpractice” instead of “mistake.”To prove malpractice in a civil court, the patient must

show the standard of care and that the nurse’s act was not“reasonable” under the circumstances, that is, it“breached” the standard. The patient must also prove thedamages and causation, that the nurse’s carelessnesscaused the alleged damages, such that they would not

have occurred otherwise. Inthese cases other parties, such asa hospital that contributed tothese damages by failing to pro-vide the required orientationfor new nurses, must also payfor damages. Most nurses havesome familiarity with these ele-ments of legal malpractice.

WHAT IS A CRIME?Like malpractice, a crime haselements that must be legally

proved in court for the person charged to be foundguilty. The elements of the offense for a crime are Mensrea, Actus reus, Concurrence of these, and Causation.3

Mens rea refers to criminal intent. That means theperson intended to do a bad act or had “malice afore-thought” or a “guilty mind.” Guilt can be attributed toa person who acts “purposely,” “knowingly,” “reck-lessly,” or “negligently.” Negligently in this context canmean that the person deliberately avoided knowingsomething that he or she should have known or thatany reasonable person would have known; for example,there might be other people in the next room whocould be harmed by stray bullets if he aims a gun at hisneighbor in the local bar.

Actus reus means that the person must have deliber-ately engaged in a criminal act. Just thinking about doinga bad act is not a crime. No matter how bad the inten-tion, no one is guilty until he or she has chosen to act (acrime of commission) or to avoid performing an act thatis legally required (a crime of omission). Concurrencemeans that the criminal intent and the criminal act mustbe related, such that the intent triggered the act. Theycan occur together, or the intent can precede the act.

Causation, as in a malpractice case, means that theactual harm must have occurred and must have occurredas a result of the criminal conduct. The prosecutionmust also prove that but for the actions of the criminaldefendant, the harm would not have occurred. If a per-son shot a gun at his neighbor intending to kill him,

Criminal punishment formistakes in a health care

setting is not only bad law,it is bad policy if it wouldresult in unreported and

repeated mistakes.

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but the bullet killed someone in the next room, thedefendant may be guilty of murder because he intendedto and did engage in a criminal act, even though he hita different victim. If he shot at his neighbor, but thebullet did not hit his neighbor or anyone else, that per-son cannot be found guilty of murder. He may befound guilty of a different crime, because the type ofharm that his actions caused (endangering others orcausing them fear of immediate harm) is different. Hadhe ultimately chosen not to shoot, there would havebeen no harm and thus no crime.

HOW IS A MISTAKE LIKE A CRIME?There are reasons that we do not think of a crime in thesame breath with an “honest mistake” that any one of uscould make. First, crimes generally require a bad person,someone with bad intentions. Second, the person whocommits a crime has deliberately engaged in an act thathe or she knows is harmful to society or against the law.

Third, unlike a malpractice case, where the wrong isagainst an individual patient, a crime is a wrong againstsociety in general. Because crime is an act against “thepeople” rather than against an individual, the burden ison the state (government) to prove the wrongdoing.Furthermore, unlike a malpractice case, where the guiltyparty must pay money damages to make amends to theinjured patient, the person guilty of a crime may lose hisor her liberty. He or she may be required to spend timein prison as punishment or to protect society from thedanger posed by their presence. Depending on the levelof the crime, the defendant can also lose his or her rightto vote in future elections.

Personal liberty is a right protected by the UnitedStates Constitution. Amendment 5 protects this in partby guaranteeing that no person “shall be compelled inany criminal case to be a witness against himself…”That means that the criminal must be advised that he isnot required to testify about the wrong act. This alsomeans that the person who has committed a crime or awrong against society has no duty to report the act.That would be self-incrimination.

Obviously, it is possible to commit a crime in healthcare. For example, theft of a patient’s valuables is a crime,regardless of whether the victim is a patient. Mens rea,actus reus, concurrence, and causation of the harm can allbe proven to show a crime, as they can in any othertheft. If a health care provider knowingly harmed a

patient—for example, independently chose to end thelife of a patient because the provider felt that the patient’slife was not worth living—the elements of a crime mayall be found, and the provider would be guilty of acrime, regardless of the setting.

How is a crime like a mistake? Beyond the fact thatboth may result in harm to another, a crime and a mistakeare not alike. A mistake lacks all of the elements of acrime. A nurse who mistakenly gives a patient the wrongmedication has no Mens rea. A mistake is the act of a per-son who had no intention to harm, but intended to dosomething else, often to help society. A mistake also hasno Actus reus, no deliberate engagement in a criminal act.Since concurrence requires both of the above elements, amistake does not qualify. Even if a mistake causes harm,this is not causation that is a result of criminal conduct. Anurse’s mistake that causes harm may be the result ofmalpractice if the mistake is shown to exhibit unreason-able professional practice.

Part of our strategy to stop criminal acts is to use theloss of liberty and the fear of loss of liberty as a punish-ment and deterrence. Liberty is highly valued in oursociety. One result in our criminal justice system is thatthe guilty party is advised not to share information about thewrong act. This is contrary to modern safety theory inhealth care. To reduce future errors in health care andpromote patient safety, nurses and other caregivers areadvised to report and share as much information as possible, assoon as possible about a mistake. Under the threat of crim-inal prosecution for an unintentional error, would theConstitution protect professionals from any duty reportor share information about a mistake as possible self-incrimination? Criminal punishment for mistakes in ahealth care setting is not only bad law, it is bad policy ifit would result in unreported and repeated mistakes.

WHY IS CRIMINALIZATION OF HEALTH CARE ERROR ATHREAT TO PUBLIC WELFARE?Safety experts—including the Institute for SafeMedication Practices,4 The Joint Commission,5,6 theInstitute of Medicine,7-9 the American NursesAssociation,10 the Agency for Health care Research andQuality,11,12 the Council on Graduate Medical Education(CGME),13 the National Advisory Council on NurseEducation and Practice (NACNEP),14 the NationalAcademy for State Health Policy,15 the Leapfrog Group(www.leapfroggroup.org), the National Coordinating

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Council for Medication Error Reporting andPrevention,16,17 the Flight Safety Foundation,18 theCommittee for Disaster Medicine Reform,19 and theCenter for Nursing Advocacy,20 among others—havefound that the system we work in is the root of many ofour safety problems. Errors are usually the result of sys-tem failures rather than an individual failure. These canonly be reduced by examining the system. TheAccreditation Council for Graduate Medical Education(ACGME) and the AmericanBoard of Medical Specialties(ABMS) identified systems-based practice (SBP) as 1 of the6 core competencies in whichphysicians must be proficient todeliver patient care that is safeand high in quality.21

The best strategy todecrease mistakes requires prac-titioners to come together to examine the variables thatcontributed to the error and remove them. This approachmakes it clear that punishment of the individual whohappens to be the last one in the chain of events isunjust. It also requires that health care have a system thatpromotes the earliest and most complete reporting oferrors possible. That is why safety and professional groupsadvocate against the criminalization of error.

Large nursing employers, such as hospitals, have poli-cies and procedures to facilitate reports of mistakes andany failures in the health care system. Incident reportsand easy anonymous reporting encourage identificationof system flaws that allow errors. Facilities have programsfor quality assurance, risk management, and qualityimprovement that are designed to identify changes thatimprove our workplace safety, patient outcomes, compli-ance with common objectives, and integrity. Errorreporting and analysis are essential practices that societyneeds to promote safe practices in health care.

The Joint Commission sets standards for health careorganizations and issues accreditation to institutions thatmeet those standards. In 2006 the commission took theposition that solutions must make health care systemssafer and prevent mistakes from reaching patients insteadof focusing on individuals, stating, “[E]everyone needs tounderstand that human error is inevitable; we need toavoid blaming individuals and begin to develop solutionsthat will make our systems better able to defend against

mistakes, preventing them from reaching our patients.”22

When investigating, emphasis should be placed on prob-lem-solving rather than on blame.23

The American Nurses Association’s (ANA) Code ofEthics for Nurses24 identifies patient advocacy as a dutyfor nurses. How can nurses meet the ethical obligation tocorrect what goes wrong and protect future patients ifwe cannot discuss mistakes? How will it impact therecruitment of qualified nursing students?25 What impact

would this have on the publicwelfare? “The implications forpatient safety are significant.Criminalizing unintentionalhuman mistakes undermineserror reporting and the creationof a culture of safety, demoral-izes providers, accelerates theexodus from clinical practice,contributes to a culture of

blame, and perpetuates the unachievable expectation ofperfection in practice.”26

CRIMINAL CASESCriminalization of errors in professional practice is a realconcern for nurses, since there have been cases againstnurses in addition to other professionals. These practi-tioners were the subject of complaints involving variousscenarios, such as medication errors, abandonment, anddisaster response. Data about the number and outcomesof criminal charges or prosecutions of professionals forunintentional error is not collected for the United Statesbut is apparently small. When such a case occurs, it canhave a disproportionate effect, since it may generate con-siderable publicity and many nurses are likely to hearabout it. Here are some high-profile cases:

• In 1996, 3 nurses at Centura St. Anthony HospitalNorth, outside Denver, Colorado, were chargedwith administering the wrong dose of a medicationto an infant, who died. Two of the nurses pled guiltyin a plea bargain, but 1 nurse refused and wasacquitted by a jury.27

• In July 2006, a nurse in Madison, Wisconsin, wascriminally charged28 after she mistakenly hung a bagof epidural anesthetic instead of penicillin, resultingin its intravenous administration and the death of amaternity patient.29 The Wisconsin HospitalAssociation,30,31 the Wisconsin Nurses Association,

Errors are usually the resultof system failures rather

than an individual failure.

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the Institute for Safe Medication Practices (ISMP),and the ANA were among those who took a publicposition in this case, opposing criminal prosecutionof health workers for unintentional errors.32

• In 2006, several nurses at Methodist Hospital inIndianapolis, Indiana, were questioned by a criminalprosecutor when 6 infants received an overdose ofheparin after a pharmacy technician incorrectlystocked the medication cabinet. Three infants sur-vived. Part of the corrective action the hospital tookwas to premix this medication in neon-coloredsyringes so heparin would not be drawn fromvials.33

• In 2007, the ISMP posted 3 ongoing cases with theheading, “Criminal Prosecution of Human Errorwill likely have Long- term Consequences.”34

•• In 1 case, a 44-year-old woman from Floridadied in an emergency department after receiving8,000 mg of phenytoin IV instead of 800 mg.The experienced nurse who administered theoverdose (which required 32 vials [50 mg/mL,5 mL] from several automated-dispensing cabinetsto prepare) was targeted for criminal investigation.

•• In another case, a 2-year-old child in Ohio diedwhile undergoing chemotherapy after a pharma-cy technician mistakenly prepared her infusionusing 23.4% sodium chloride, not 0.9% sodiumchloride. The technician and pharmacist failed tonotice the error before dispensing thechemotherapy. The pharmacist was criminallyprosecuted and actually convicted.

•• In a third case, an elderly woman from Ohiodied after she received an IV injection of potassi-um phosphate that was supposed to be adminis-tered via a feeding tube. In this case, courtactions were filed to request a change in thecause of death from an accident to homicide.

• In April 2009, the ISMP posted a position state-ment opposing criminal charges for an Ohio phar-macist who oversaw the preparation of an incor-rect dosage of a chemotherapy agent for a child bya pharmacy technician, stating, “Criminal prosecu-tion of a health care professional for an uninten-tional error is inappropriate and unwarranted.Unfortunately, when a fatal medication erroroccurs, there often is considerable pressure fromthe public and the legal system to blame and disci-

pline individuals for mistakes. However, criminalprosecution sends the false message that clinicalperfection is an attainable goal, and that ‘good’health care practitioners never make errors andshould be criminally punished if they are involvedin an error. Practitioners begin to fear disciplinaryaction if they make a mistake, and reporting oferrors decreases, making it more difficult to deter-mine the true cause of the errors.”35

• In December 2008, in San Luis Obispo, Cali -fornia, Dr. Hootan C. Roozrokh was acquittedafter being charged criminally with speeding thedeath of an organ donor.36 This charge was theresult of prosecutors failing to understand the dif-ference between cardiac death and brain deathcriteria in organ procurement.

• During Hurricane Katrina and its aftermath—nofood, water, oxygen, or basic medical supplies, insweltering heat, and with outside help late in arriv-ing—nurses and doctors at Memorial MedicalCenter in New Orleans (themselves victims of thedisaster) were unable to save all of their patients. TheLouisiana attorney general charged 1 physician and2 nurses with euthanasia.37 Eventually, charges weredropped against the nurses in return for their testi-mony, and in July 2007 a grand jury refused toindict the physician.38 The Committee for DisasterReform (www.cdr.org) grew out of this event.

• A social worker in New York and his supervisorwere indicted in March 2011 on charges of crimi-nally negligent homicide by the Brooklyn districtattorney, who alleged that their failures contributedto the death of a 4-year-old girl. The child’s motherwas indicted for murder, and her grandmother formanslaughter. According to The New York Times: “Itwas believed to be the first time in the city’s historythat child welfare workers had been charged withhomicide in a child’s death, and the district attorney,Charles J. Hynes, made it clear that he did notbelieve they were the only ones to blame. Mr.Hynes said he was convening a special grand jury toinvestigate “evidence of alleged systemic fail-ures”(emphasis added) at the child welfare agency,the Administration for Children’s Services. Thegrand jury will seek to determine whether theagency had followed through on its plan for reformsafter the 2006 death of Nixzmary Brown, a 7-year-

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old Brooklyn girl, one of a long series of abuse andneglect deaths that have pockmarked the city’s halt-ing efforts to protect its large numbers of vulnerablechildren.”39

WHAT CAN APRNs DO?APRNs are likely to be more aware than most nurses oftrends and issues related to the potential negative falloutof criminalized professional mistakes, such as the discour-agement of recruitment into health care professions, errorreporting, participation in lifesaving organ donation, andvolunteering in disaster. Treating health care workers whohave made an error as if they were criminals could notjust chill reporting of errors but freeze it. In response,APRNs must join other professionals in emphasizing theneed to move the focus from blaming the individual forbad outcomes in health care systems.

Taking a stand against acts by prosecutors to crimi-nalize mistake is a critical part of this process. Nurses andother health care professionals need to work togetherproactively to educate the legal community, enforce thepolicy against the criminalization of error, support evi-dence-based policies that will make patient care safer (eg,Joint Commission), and advocate for changes in law andregulation that reflect this policy. Joining an authoritativeprofessional organization is 1 act that every APRNshould take to effectively advo-cate for nursing and for patientsafety. Membership in a profes-sional organization potentiatesthe efforts of each member topromote effective policy.APRNs must work with ANA,state ANA affiliate organiza-tions, the Nurse PractitionerAssociation, and professionalspecialty organizations to pro-mote legislation or take othermeasures to protect health careprofessionals from inappropriate and harmful criminalcharges for mistakes in the workplace or for reportingsuch mistakes.

Some ANA affiliate organizations are leading theway in this effort. The Texas Nurses Association, theWisconsin Nurses Association, and the Ohio NursesAssociation—all states where the awareness of thisproblem was raised by high-profile cases against

nurses—successfully advocated for legal changes to pro-tect nurses who report mistakes or dangerous situationsin the workplace that could result in error. Their workis available on their Web sites, and it can serve as mod-els for other organizations.

APRNs can also work with other professional groupsoutside of nursing and with groups such as the AmericanAssociation of Nurse Attorneys (TAANA), a professionalorganization that bridges nursing and law.

As important stakeholders of their professional statelicensure boards of nursing, APRNs can also urge regula-tors at the state nursing boards to adopt the Just Culturemodel. This is a recent concept in health care but hasbeen an initiative in other high-risk professions, such asaviation. This model is designed to create an organiza-tional culture of safety to prevent errors by putting morefocus on risk and system design and less on events anderrors.40 Nursing boards in North Carolina, Minnesota,Missouri, and Texas have expressed interest in examiningthis model for nursing regulation.

The National Council of State Boards of Nursingfunded an Institute of Regulatory Excellence report onJust Culture in 2007 by North Carolina Board ofNursing staff members Chastain and George.41 The focusof regulatory boards, which grant and can take away pro-fessional licenses, is very influential in health care. If their

response to reports of error ispunitive, that can be a majorbarrier to promoting patientsafety as the response of institu-tions and the legal system. Iftheir response is evidence-based, they can be leaders ineducating professionals and thepublic in promoting a cultureof safety. Nursing boards canalso be a resource for otheragencies whose responsibilitiessometimes overlap that of the

boards in protecting the public. This includes expandingtheir collaboration with law enforcement, which some-times is called on to enforce other laws related to nursinglicensure and practice, such as drug diversion, or toreport nurses who have been convicted of crimes thatmay reflect moral turpitude.

The Institute of Medicine’s 2004 report To Err IsHuman: Building a Safer Health System stated, “The focus

APRNs can support patientsafety by promoting a

problem-solving approachto mistakes in health care,one that maintains a focuson the system and rewards

rapid reporting.

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must shift from blaming individuals for past errors to afocus on preventing future errors by designing safety intothe system …When an error occurs, blaming an individ-ual does little to make the system safer and preventsomeone else from committing the same error. Healthcare is a decade or more behind other high-risk indus-tries in its attention to ensuring basic safety.”9 We need toexamine how nursing education can more effectivelyaddress the need for APRNs to be collaborative membersin health care42 and to be competent in working withsystems, as physicians are doing.43

Above all, as nursing leaders, APRNs can supportpatient safety by promoting a problem-solving approachto mistakes in health care, one that maintains a focus onthe system and rewards rapid reporting. APRNs must usetheir knowledge of systems to support an institutionalresponse to error that focuses on root cause analysis(RCA)44 in response to sentinel events, as currently man-dated by The Joint Commission. Root causes of sentinelevents reported to The Joint Commission have consis-tently included deficiencies in communication, orienta-tion, and training; patient assessment; staffing; availabilityof information; competency or credentialing; proceduralcompliance; environment of care; leadership; continuumof care; plan of care; and organizational culture.Institutional response must also include failure mode andeffects analysis (FMEA),45 which proactively identifiesand assesses risks to redesign the system before it fails.APRNs must support a response to error that combinesRCA and FMEA.

Edie Brous, JD, RN, (oral communication, May2011) a practicing nurse attorney in New York Cityand the current president of TAANA, summed this upwell when she said, “Nursing care is a high-risk activityand should be provided in a culture that understandsthat, builds redundancies into its systems, people-proofsits processes, and takes responsibility as an organizationfor making the shift from blaming individuals toimproving systems. Punishing providers does not keeppatients safe. Improving systems with non-punitiveerror analysis does.”

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3. American Law Institute. Model Penal Code. Philadelphia, PA: ALI; 1962.

4. Institute for Safe Medication Practices. Criminal prosection of human error willlikely have dangerous long-term consequences. ISMP Medication Alert! March2007. http://search.ismp.org/ cgi-bin/hits.pl?in�517791&fh�80&ph�1&tk�xwarJrvei%20warJrveiqf%20 warJrveif&su�eTuuEyBBppp.-PWE.VkABszpP%26zuuzkPBOgwuzgOkzBOku-g%26zPB20070308.OPE&qy�pKFepeb%26L&pd�1.Accessed May 20, 2011.

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11. Johnson JK, Miller SH, Horowitz SD. Systems-based practice: improving thesafety and quality of patient care by recognizing and improving the systemsin which we work. http://www.ahrq.gov/downloads/pub/advances2/vol2/Advances-Johnson_90.pdf. Accessed on May 18, 2011.

12. Agency for Health Care Research & Quality. Ten patient safety tips forhospitals. 2007. http://www.ahrq.gov/qual/10tips.htm. Accessed April 19,2011.

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14. Council on Graduate Medical Education & National Advisory Council onNursing Education and Practice. Collaborative Education to Ensure PatientSafety. Washington, DC: US Department of Health & Human Services HealthResources and Services Administration; 2000.

15. National Academy for State Health Policy. Opportunities andrecommendations for state-federal performance: a focus on patient safety.2010. http://www.nashp.org/sites/default/files/Patient_Safety_1-12-10.pdf.Accessed May 18, 2011.

16. The National Coordinating Council for Medication Error Reporting andPrevention. Reducing medication errors associated with at-risk behaviors byhealth care professionals. www.nccmerp.org/council/council2007-06-08.html.Accessed April 1, 2011.

17. The National Coordinating Council for Medication Error Reporting andPrevention. Statement opposing the criminalization of errors in health care.2011. http://www.nccmerp.org/council/council20011-05-01.html. AccessedMay 1, 2011.

18. The Flight Safety Foundation. Joint resolution regarding criminalization ofaviation accidents. 2006. http://flightsafety.org/files/resolution_01-12-10.pdf.Accessed April 19, 2011.

19. Committee for Disaster Medicine Reform. http://www.cdmr.org/concern.html.Accessed March 8, 2011.

20. Center for Nursing Advocacy. Error and punishment. 2006. http://www.nursingadvocacy.org/news/2006/nov/20_captimes.html. Accessed May 20, 2011.

21. Stewart MG. Accreditation Council for Graduate Medical Education Corecompetencies. 2001.http://www.acgme.org/acwebsite/RRC_280/280_corecomp.asp. Accessed May20, 2011.

22. Joint Commission. Strategies for building a hospitalwide culture of safety.Safety Initiatives. Oakbrook Terrace, IL: Joint Commission Resources; 2006: 1.

23. Joint Commission. Front Line of Defense: The Role of Nurses in PreventingSentinel Events. 2nd ed. Oakbrook Terrace, IL: Joint Commission Resources;2006.

24. American Nurses Association. ANA code of ethics for nurses withinterpretive statements. 2001. http://www.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/EthicsStandards/CodeofEthics.aspx. Accessed April 19, 2011.

25. Joint Commission. Health care at the crossroads: Strategies for addressingthe evolving nursing crisis. 2002. http://www.aacn.nche.edu/media/pdf/JCAHO8-02.pdf. Accessed April 22, 2011.

26. Brous E. Criminalization of unintentional error: Implications for TAANA. JNurs Law. 2008;12:1. http://findarticles.com/p/articles/mi_7614/is_200804/ai_n32276488/?tag�mantle_skin;content. Accessed April 1, 2011.

27. Plum SD. Nurses indicted: three nurses may face prison in a case that bodesill for the profession. Business Network. 1997.http://findarticles.com/p/articles/mi_qa3689/is_199707/ai_n8766289. AccessedMay 1, 2011.

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28. State of Wisconsin v. Julie Thao, Circuit Court, Dane County, CriminalComplaint, Case Number 2006 CF 2512. http://www.thedailypage.com/media/2006/11/22/ThaoComplaint.pdf. Accessed May 1, 2011.

29. Arp J. State investigations cite St. Mary’s for deficiencies. 2006.http://www.channel3000.com/news/9558313/detail.html. Accessed May 18,2011.

30. Wisconsin Hospital Association. Nurse charged with criminal neglect formedical error appears in court, ISMP: Criminal charge “inappropriate andunwarranted.” Valued Voice. 2006;50(42). http://www.wha.org/pubArchive/valued_voice/vv11-10-06.htm. Accessed May 18, 2011.

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1555-4155/11/$ see front matter© 2011 American College of Nurse Practitionersdoi: 10.1016/j.nurpra.2011.07.006