Blame cultures

In some organizations, designated individuals have specific responsibility for eliciting detailed information from operational staff on the immediate and underlying causes of incidents. An example is the Human Performance Evaluation System (HPES) developed for the nuclear industry, which is described in Bishop and Larhette (1988). These coordinators provide a certain level of guaranteed irrununity from sanctions which allows individuals to be frank about the contributory causes that they may not be willing to discuss in an open forum. As discussed earlier, the need for this approach is a consequence of the fact that in many organizations a blame culture exists which is likely to inhibit a free flow of information about the causes of accidents. 

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. 

Tumheim K (2004) Drug therapy in the elderly. Exp Gerontol 39 1731-1738 Wise J (2001) UK government and doctors agree to end blame culture . BM1 323 9... 

Holistic approach All round feedback Cultural change — allows rapid response in changing world Achieves business objectives Complexity Most intensive in research and preparation Needs a no-blame culture May raise expectations that are difficult to deliver... 

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. 

Even Lord Cullen, as quoted by the HSE, recommended a no-blame culture to the British Rail industry when he said,... 

I recommend to the industry the development of an acts and blame culture in which information is communicated without fear of recrimination and blame is only attached when this is justified. (HSE, 2005, p. 7)... 

Dislike of medical treatment Loyalty to team Blame culture... 

Declaration of safety amnesty (no-blame culture) A safe space... 

There is too often a blame culture. When things go wrong, the response is to seek one or two individuals to blame, who may then be subject to disciplinary measures or professional censure. That is not to say that in some circumstances individuals should not be held to account, but as the predominant approach this acts as a significant deterrent to the reporting of adverse events and near misses (Department of Health, 2000, p. 77). 

The tendency for excessive, immediate and unreasoning blame in the face of patient harm, both from within and outside healthcare organizations, has led some to call for a no-blame culture. This, if taken literally, would appear to remove personal accountability and also remove many social, disciplinary and legal strictures on clinical practice. A culture without blame would therefore seem to be both unworkable and to remove some of the restrictions and safeguards on safe behaviour. A much better objective is to try to develop an open and fair culture, which preserves personal responsibility and accountability but requires a much more thoughtful and supportive response to error and harm when they do occur. 

Many factors have been highlighted as supporting the development of an effective patient safety culture. Some of the important ones are management (i.e., management commitment, ability, leadership, coordination, and flexibility), immediate supervisors (i.e., open-door policy, participation, and support correct behavior), reporting system (i.e., reporting near-miss, no-blame culture, analysis of error, open-door policy, confidentiality, and feedback). 

Needs a no-blame culture to encourage employees to report matters. 

Given the right circumstances, these systemic methods can facilitate a positive shift from a blame culture through no blame and towards a just culture approach to safety investigation, and to the reporting of normal errors . 

Whittingham asserts that in some organizations, a blame culture exists whereby the focus in the investigation of incidents resulting in severe consequences is on individual human error, and the corrective action taken occurs at that level, rather than within the system that may have enabled the human error. He stresses that placing responsibility for the incident on what an individual did or did not do results in overly simplistic causal factor determination. 

Attimdes toward blame will determine whether or not an organization develops a blame culture, which attributes error to causes such as lack of motivation or dehberate unsafe behavior. 

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