The system is broken-not the nurses

A medication error, a patient fall, or a delay in care, and suddenly the nurse is under investigation, facing disciplinary action, or even termination. But what if we pulled back the curtain and looked deeper? What if the real culprit wasn’t the individual nurse, but rather the flawed systems, poor design, and broken processes that have existed in healthcare for far too long?

Nurses are the most visible members of the healthcare team, spending more time with patients than any other discipline. Because of this visibility, when an error occurs, the nurse is typically the first (and often only) person held accountable — regardless of the underlying system failures that contributed to the mistake. It’s a dangerous and deeply unfair dynamic that not only harms nurses but also stunts progress toward real patient safety improvements.

The Medication Error that Wasn’t Entirely the Nurse’s Fault

Consider the case of medication administration. Nurses are tasked with administering medications under the “Five Rights” — right patient, right medication, right dose, right time, and right route. But picture this:

• A nurse is caring for seven patients during a shift — well beyond the recommended safe staffing ratios.
• The hospital’s medication dispensing system (like a Pyxis or Omnicell) frequently overrides medication warnings to keep patient flow moving.
• The electronic health record (EHR) provides pop-ups that are easy to miss when documenting in high-pressure environments.
• The pharmacy has mislabeled a medication, but the nurse is expected to catch the error in the few seconds they have to administer it.

If a medication error occurs under these conditions, the immediate response from leadership is often to investigate the nurse. Why didn’t the nurse catch the error? Why didn’t the nurse slow down and double-check everything? Rarely does anyone ask why the system allowed the medication to be mislabeled in the first place, why the nurse was caring for too many patients, or why the technology wasn’t designed to flag such errors more effectively. The system failed — but the nurse carried the blame.

Patient Falls: A Design Failure, Not a Nurse Failure

Another example is patient falls in hospitals or long-term care facilities. Suppose a patient who is a high fall risk gets out of bed without assistance and falls, resulting in injury. The immediate question is: Where was the nurse?

But let’s look closer:

• The call bell system was outdated or malfunctioning, leaving the patient unable to call for help.
• The hospital cut staffing to save money, resulting in one nurse caring for too many high-risk patients.
• Bed alarms were either turned off to reduce noise or never installed in the first place.

Instead of examining the lack of resources, staffing, or effective safety measures, hospitals often go straight to blaming the nurse. The nurse is reprimanded for “failing to anticipate the fall,” even though the facility itself failed to invest in patient safety measures. Once again, the system failed — but the nurse carried the blame.

Delayed Care Due to System Failure

A particularly heartbreaking example is delayed patient care. Imagine an Emergency Department (ED) where patients are lined up in hallways due to overcrowding. Nurses are working under crushing patient loads, and despite their best efforts, some patients wait hours for critical interventions. When a patient suffers a poor outcome due to a delay in care, the immediate reaction from hospital leadership is often: Why didn’t the nurse act faster?

But here’s what really happened:

• The hospital was understaffed due to budget cuts.
• The triage system was outdated, delaying patients from being seen based on their acuity.
• The nurse had five or six high-acuity patients to monitor at once — an impossible task.

Instead of examining why the hospital allowed unsafe staffing levels or poor triage systems, the nurse becomes the scapegoat. They may face a formal complaint, suspension, or worse, even though the delay was largely a system failure.

Why This Keeps Happening

The real reason nurses continue to shoulder the blame is that it’s easier for healthcare institutions to point fingers at an individual than to admit that their systems are broken. Fixing a faulty medication delivery process, investing in better technology, or improving staffing ratios costs money — disciplining a nurse does not. Additionally, admitting to systemic failures opens the door to lawsuits or regulatory scrutiny, so hospitals default to blaming individuals to protect themselves.

This blame culture has long-reaching consequences. Nurses become burned out, demoralized, and fearful of making mistakes. Some even leave the profession entirely. But the most devastating consequence is that patient safety doesn’t improve — because the root causes of the errors remain unaddressed.

What Needs to Change

If healthcare leaders are serious about patient safety, they must shift their mindset from blame to accountability. Accountability doesn’t mean punishing individuals — it means examining the systems, processes, and structures that lead to errors in the first place.

• Hospitals need to invest in better staffing models. Expecting a single nurse to safely care for eight patients is a design failure — not a nursing failure.
• Technology needs to support nurses, not burden them. Streamlining medication administration systems, reducing unnecessary documentation, and creating fail-safe mechanisms would drastically reduce human error.
• Processes need to prioritize safety over speed. Rushing care to improve patient throughput may increase profits, but it also increases preventable errors.

It’s time to stop blaming nurses for problems they didn’t create. Until we address the design, process, and system failures in healthcare, we will continue to burn out our nursing workforce — and put our patients at risk.

The next time you hear about a nurse being blamed for an error, ask yourself: What part of the system failed them first?

Call to Action: Share Your Story

Nurses, I know many of you have been in this exact position — blamed for an error, a patient outcome, or a process failure that was ultimately caused by a broken healthcare system. It’s a story that happens far too often, and it’s time we start talking about it.

I want to hear from you. Have you ever been blamed for a mistake or failure that was actually caused by poor staffing, faulty systems, or flawed processes? Maybe it was a medication error, a patient fall, or a delayed response — but deep down, you know the system failed first, not you.

👉 Share your story in the comments below. What happened? How did it make you feel? What do you wish would change in healthcare to prevent it from happening again?

Your voice matters. The more we speak up, the harder it becomes for healthcare systems to ignore the real problem — and the closer we get to real change.

Let’s stop the blame — and start fixing the system. 💙🩺