The importance of a ‘no blame’ culture in the NHS has become axiomatic. It is accepted that the chain of learning that connects adverse healthcare events to improvements in safety is fatally interrupted when incidents are not reported. If people fear blame and censure, they will not report. Berwick focussed on this in his 2013 post-Francis report, ‘A promise to learn – a commitment to act Improving the Safety of Patients in England’. It says,
Patient safety problems exist throughout the NHS as with every other health care system in the world.
NHS staff are not to blame – in the vast majority of cases it is the systems, procedures, conditions, environment and constraints they face that lead to patient safety problems.
Fear is toxic to both safety and improvement.
To address these issues the system must:
– Recognise with clarity and courage the need for wide systemic change.
– Abandon blame as a tool and trust the goodwill and good intentions of the staff.
As a doctor who is involved in mortality and morbidity meetings, I often think about the role of blame in learning lessons. At my level medicine consists of numerous interactions between just two or three kinds of people; patients and doctors/nurses. If a mistake is reported an assessment is undertaken as to whether that mistake was due to a fault in the system (eg. poor process, unclear guidelines, bad IT, poor labelling) or a restricted error on behalf of the health care worker. The latter might include mistakes due to a lack of knowledge, or due to a lack of concentration. But what if the lack of concentration is the result of unintelligent rota design, or distraction due to an over-burdened system? The spectrum of potential accountability is wide, but whenever an error is identified it is necessary to see at what point on that spectrum the underlying cause lies. Or the blame.
Example: a junior doctor gives a patient an antibiotic that she is allergic to, the doctor having failed to recognise that the trade name (let’s say Tazocin) disguises the fact that it contains penicillin. The patient has an anaphylactic reaction and spends a week on intensive care.
The focus of accountability could reasonably fall on one of several points. It could be the doctor not being aware that the antibiotic contained penicillin, or for not checking that the patient was allergic. For not bloody thinking, his exasperated supervising consultant might say to herself, immediately succumbing to the emotional retort that is ‘blame’. Or, could it be the doctor’s educators who have not emphasised that fact in his training? Or the drug firm for releasing a medication which does not make its crucial ingredient plain? Or the Trust for not being responsive to the fact that this doctor is routinely over-pressurised at night, and making decisions in a hurried way. Or the Department of Health for capping central funding, or David Cameron for supporting a policy of austerity… or mortgage lenders in America for contributing to the 2007 financial crisis.
This begins to sound sounds absurd, but the point I’m trying to make is that the chain of blame could be a long one. And when you make a mistake, it is natural to look up and around for mitigating circumstances.
Now imagine that the junior doctor is brought into his educational supervisor’s office. It is explained that the patient came to harm because the doctor prescribed the drug to which the patient was known to be allergic. It’s my fault, is how the doctor will feel. But the educational supervisor will be quick to soften the criticism by explaining that there will be a review of systems, more nurse education so that injections are not actually given if it says penicillin allergy on a drug chart, and the Trust will arrange some extra pharmacology teaching for House Officers. Use of the misleading trade name will be banned. The system has learned. It’s not your fault.
Immediately the sense of blame rises from the shoulders of the junior doctor and it becomes clear to him that it is not just his problem. Should that doctor walk out of the room with no sense to blame? Well, I can recall most of the mistakes that I have made in my career, and the intense sense of blame and guilt that accompanied them. Whether it was mismanaging Gentamicin and causing renal failure, missing a cord compression or making a late diagnosis on data that I should have interpreted correctly. It is blame, the sense of personal responsibility, that nagged at my mind and made sure I never made the same mistake again. For this reason I think individual blame does have a role. And I am not alone. A National Patient Safety Agency presentation from 2004 includes these slides:
At least 90% of error can be attributed to system problems or ‘honest’ errors, while only a small percentage are deemed ‘culpable’. This data is largely derived from the aviation industry, where many parallels with healthcare have been identified. But even this presents problems. The ‘honest error’ is still an error. Just because it is honest (ie. not intentional or negligent, an error that quite would probably have been committed by a peer in the same combination of circumstances) there is still something to be learned by the individual.
The psychologist James Reason describes person and system approaches. The former attributes unsafe acts to,
aberrant mental processes such as forgetfulness, inattention, poor motivation, carelessness, negligence, and recklessness.
Whereas a system approach accepts that,
humans are fallible and errors are to be expected, even in the best organisations. Errors are seen as consequences rather than causes, having their origins not so much in the perversity of human nature as in “upstream” systemic factors.
For those of us dealing with error on a day to day basis, an approach that tackles individual blame while paying heed to system-wide lessons must be taken. For reporting to be encouraged, blame must not apportioned in public… for that is where shame develops, and its lethal consequence – inhibition. But in private, as we look at near misses and significant errors, we will sometimes accept that it really was a silly thing to do. And we will not hide our concern, nor conceal our disappointment if the error appears to indicate a worrying gap in knowledge, method or attitude. If this is the case a way must be found to lighten the sense of personal blame by looking up at systemic factors (if present), but without allaying personal discomfort entirely. In this way we (for it will happen to all of us at some point) will remain alert, and perhaps even a little paranoid, when we enter a similar clinical scenario in the future.