Medication errors are rarely the result of one person making an error. There can be many factors that can contribute to an error. Blaming the person who made the mistake without getting to the root of the problem will not prevent the same mistake from being made by someone else. Reviewing incident reports and suggesting safer ways to prescribe, package, dispense or give medication is a better way to prevent harmful errors.
When we review reports, we are looking for the problems that caused the error so that we can recommend ways to make the system safer. This is a much better way to prevent errors than punishing the person who made the mistake.