Blameless environment

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. 

We have three ground rules for this discussion. First, this is a blameless environment. We are not here to find a scapegoat but to identify failures in our operating system. We want to reveal all of the issues and problems in an open discussion. Second, this process is confidential. Please do not reveal the name of the patient or the identity of the caregivers. Third, we ask you to think creatively about how to improve our systems and processes. Try to envision the patient as your own child and to identify systems that you would like to have in place to ensure your child s safety [Edmondson, Roberto, and Tucker, 2001, p. 2]. 

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