Culture blame-free

As discussed earlier in this chapter, the main requirements to ensure an appropriate safety culture are similar to those which are advocated in quality management systems. These include active participation by the workforce in error and safety management initiatives, a blame-free culture which fosters the free flow of information, and an explicit policy which ensures that safety considerations will always be primary. In addition both operations and management staff need feedback which indicates that participation in error reduction programs has a real impact on the way in which the plant is operated and systems are designed. 

Set up a blame-free culture when possible and appropriate. Employees should be willing and able to report safety problems they observe without fear of repercussion. Exceptions to this include situations where employees clearly violate rules or safety procedures, (personal communication)... 

A risk assessment can be performed retrospectively or prospectively. If an adverse event - whether a complaint, a deviation or adverse effect - happens it will be analysed retrospectively. Staff will be convinced about the necessity for any action. When staff do not report incidents however or do not qualify them as important the improvement process may be missed. For risk assessment a blame-free culture in the organisation is very important. 

Compliance embedded in day-to-day activities Key risk indicators with established limits, monitoring of safety risk within limits, corrective actions when thresholds exceeded Leadership and managers demonstrate safety Staff support safety daOy Blame-free culture Safety focus on creating value to business units at a competitive price... 

Nurturing a blame-free, open culture within an organization is essential for the success of the incident investigation process. The investigation must focus on understanding ... 

How individuals within an organisation are expected to prioritise safety in then-day to day work as part of a safety culture and how concerns can be raised in a blame-free, non-prejudicial manner. 

Dr. Mark A. Friend (2012) also mentions creating a blame-free environment as a prerequisite for safety culture change ... 

Partial resnlts in the Japanese snrvey are shown in Table 4.2 in terms of the percentage of positive respondents for each factor of safety culture as well as significance levels across fom professional groups - although every factor was significantly different. As an overall trend, almost all Japanese healthcare professionals have a strong awareness of communication as well as strong respect for seniority and senior members. There is a small power distance as well as a blame-free atmosphere within a hospital. 

From these resrrlts, it can be seen that a positive safety culture contributes to favorrrable staff attitudes related to patierrt safety. In particular, small power distance arrd blame-free atmosphere appeared as the most effective elements of safety crrlture for positive staff attitrrdes and behaviours to error reporting and interaction with the patierrt after the adverse event. 

Are there traditions and systems for the detection and blame-free exploration of biases and errors, and for sharing lessons learned These cultural attributes and practices are fostered by a strong transformational leadership style (see chapters 4 and 5) and reflected in high scores on the OCDI s four organizational dimensions (procedural justice, perceived organizational support, leader-member exchange, leadership credibility). 

Reports of equipment failures, design faults or procedures which might cause a hazard, must be encouraged without threat of disciplinary action wherever possible. An effective safety culture requires an atmosphere in which individuals are not unduly punished or blamed for their mistakes - a blame-free environment. This is an ideal which is difficult to achieve in practice when things really do go wrong, people s reaction is often to protect themselves by pointing the finger of blame at others. 

Even an organisation that strives to achieve a blame-free environment is still subject to rules and legal regulation. A just culture is one in which individuals are not free of blame if they are culpably negligent and where the organisation gives due regard to honesty (David, 2002). 

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. 

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