Install a Blameless Reporting System

Many medical accidents can be predicted and prevented if near misses and risk-prone conditions can be made transparent. High-risk industries employ systems of reporting to improve the safety of their environments and reduce harm. Health care can do likewise. 

Assigning human error as the cause of medical accident allows the health care culture to reinforce an illusion of restored safety when the individual in error is removed. This approach denies the existence of system failures, identifies a scapegoat, and prevents learning. It truncates the ability to predict and prevent future adverse events. Later, after the human cause of an accident is removed, another human being will step into place. The same conditions and factors can be reassembled, and the stage is set for the medical accident to recur. 

The purpose of a blameless voluntary reporting system is to help people learn. It has the following clear and specific goals  

Designing fail-safe care delivery processes that deflect system errors and system vulnerabilities before they reach a patient to create harm 

Facilitating more informed decision making for patients, providers, and clinicians 

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Designing and installing a blameless reporting and learning system... 

Installing a blameless voluntary reporting system is a powerful cultural intervention to create transparency of errors and latent conditions so that learning can occur and zones or margins of safety can be identified. 

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