Blame and punishment

Chapter 1, The Role of Human Error in Chemical Process Safety, discusses the importance of reducing human error to an effective process safety effort at the plant. The engineers, managers, and process plant personnel in the CPI need to replace a perspective that has a blame and punishment view of error with a systems viewpoint that sees error as a mismatch between human capabilities and demands. 

This chapter has provided an overview of the book and has described its underlying philosophy, the system-induced error approach (abbreviated to the systems approach in subsequent chapters). The essence of the systems approach is to move away from the traditional blame and punishment approach to human error, to one which seeks to understand and remedy its underlying causes. 

Promoting a Just Culture requires getting away from blame and punishment as a solution to safety problems. One of the new assumptions in chapter 2 for an accident model and underlying STAMP was ... 

Blame and punishment discourage reporting problems and mistakes so improvements can be made to the system. As has been argued throughout this book, changing the system is the best way to achieve safety, not trying to change people. 

When there is less fear of blame and punishment, people become more open to discussing errors and near misses (Barach and Small 2000). Near misses are an important source of information as they are accidents that almost happened. Since they differ only slightly from accidents, they can teach us a lot about causes of error in a workplace. This is described by (Reason 1990) in his Swiss cheese model seen in Figure 3.2. There are a variety of factors that affect whether or not an accident occurs. The factors influencing a situation are likened to slices of Swiss cheese which contain a number of holes. These holes represent weaknesses which could lead to errors. Accidents occur when the holes in each slice (or variable) align, while near misses occur when most, but not all, of the factors necessary for an accident are present. In this way, near misses can provide cracial information about imidentified risk factors. 

Blame and punishment sufficiendy motivate people to be more careful, thereby avoiding future mistakes. 

The idea of eliminating harm rather than stamping out error is a relatively new concept in health care. Not long ago, when error was attributed to the carelessness of individuals or to human mistakes, and blame and punishment were thought to be... 

The CPI would benefit from the application of human factors principles to improve safety, quality, and productivity. These arise from applying quality management to get at the underlying causc-.s of errors rather than after-the-fact blame or punishment. Crosby (1984) advocates error cause... 

All the objectives presented in Box 11.1 can be described as quality improvement in the structure and process to support improvement in each patient s health outcome. This support the patient medication care process presented in Fig. 3.1. Various problems and tools and models for improvement have been described in this book. Another approach to prevent medication errors and to improve care is to be open and continuously learn from mistakes. The basis for this is not to punish health care providers who make errors, as this may lead to less reporting of errors. In Britain, the government has taken steps away from this blame-culture (Wise 2001). In a declaration it is stated that honest failure should not be responded to primarily by blame and retribution, but by learning and by a drive to reduce risk for future patients. 

The distinctions between these two voices create a dissonance in the way the enforcement of safety works. Whilst those at the higher corporate level seek to develop and position safety only positively, through no-blame cultures and realities intolerant of violation to the point of denial, those who manage and participate in construction site practices on a daily basis at site level instead have a version of safety firmly positioned within a reality of rules, violations, enforcements and punishments. Yet this latter approach also has the potential to create an understanding, or rather misunderstanding, that safety is the rules, rather than any wider considerations of safety and practice. In fact, when the safety rules are explored in more detail, their associations with safety become rather irrelevant and the enforcement of safety is much more bound up in issues of discipline and punishment on a societal level, rather than the potential consequences of any safety violations themselves. 

Human behavior is always influenced by the environment in which it takes place. Changing that environment will be much more effective in changing operator error than the usual behaviorist approach of using reward and punishment. Without changing the environment, human error cannot be reduced for long. We design systems in which operator error is inevitable, and then blame the operator and not the system design. 

Accountability versus blame. Health care professionals are accountable for their work. They have a responsibility to possess current knowledge and competence in the work they perform they also have a responsibility to acknowledge the interdependence they have in their performance. In addition, they must appreciate how systems work and understand that people are the human components of systems, both contributing to failure and creating safety. Blame focuses on a scapegoat rather than on the pursuit of deeper understanding about failure. The traditional blame, shame, and punish methods have not worked to improve safety. Blameless versus punitive or retaliatory. A blameless environment is one where the front line is comfortable reporting failures and near misses so they can be studied in this kind of environment, the front line even feels compelled to report failures. A punitive or retaliatory environment creates an atmosphere where sharp end staff members are afraid to disclose failures and near misses, and in this way opportunities to learn from mistakes are eliminated. 

Employees will be hesitant to recall near miss incidents if the recall ends up in disciplinary measures. A near miss incident recall session should be treated as confidential and the information disclosed also should be handled with discretion. No disciplinary measures should take place. Finger-pointing and punishing people for recalling near miss incidents will stop employees participating in the near miss incident recall sessions. Where possible, the near miss incident recall should be a factfinding session and not a blame fixing or witch hunt activity. 

Another major problem with overreliance on punishment is that it discourages cooperation and problem solving. When someone criticizes our work, do we go into a problem-solving mode Do we work diligently to help resolve the problem No way What do we do We become defensive. We begin to make excuses, to rationalize, to explain why we could not have done differently, perhaps to claim how those we depend on prevented us from behaving differently or otherwise blame others. Punishment undermines the cooperation required for teamwork. 

Fear. Fear, including job insecurity, fear of blame, and fear of punishment was seen to be a barrier to learning and change. Fear was frequently described in the sessions. It is important to make a distinction here. There can be fear of a person or persons, and there can be fear of the economic uncertainties confronting the company. In this case the anployees were concerned that the company s economic performance might be weak, leading to plant closures and layoffs. These fears were reahstic, as the company had already engaged in some layoffs. 

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