Medical errors- Why don’t they get reported? What can be done to
change the culture of shame and blame? a There are a number of
reasons that medical errors don’t get reported: fear of retribution,
lack of an effective reporting system, and even disagreement about
how to measure patient harm (Poorolajal, 2015). Additional barriers
to reporting include the extra time it takes to report for already
overburdened clinicians and the perceived severity of the error
(Pharmacy Times, 2016).
a Health organizations/ governmental entities/ etc. argue that the
reporting of errors will drive a safety culture but nearly 20 years after
the initial To Err is Human report was issued, there is still no widely
adopted reporting system and systems, processes and learning to
reduce errors has had minimal impact. The airline industry, similar to
medicine has long had a culture of blame. The aviation industry
“pioneered and revolutionized the way in which failings are handled”
Radhakrishna (2015) and the health industry could learn some
valuable lessons. They moved away from blaming individuals, they
recognized that system failures area reality and they made the error
reporting and management of these issues ‘more robust’
(Radhakrishna, 2015).
a In an interesting article by Parker and Davies, they propose moving
to a culture that focuses on responsibility vs. blame. This proposed
middle path avoids the blame culture in which there are no winners
and no learnings and also avoids the ‘no blame culture’ that doesn’t
account for individual responsibility, the ability to make reparations,
personal growth that comes with owning an error and the ability to
take steps towards preventing future errors) Parker and Davies,
2020). a Other proposed solutions include an incident decision tree
(IDT) to provide support and a consistent and fair approach
(Radhakrishna, 2015). The tool could help to identify and isolate
malicious harm from those caused by errors. It would also provide an
opportunity to retrain staff.
a Healthcare is a complex environment with lots of systems and
processes. To improve outcomes and safety we need to change the
way we think. We must have a strong system to report errors and
then use the data to focus on the systems and processes that guide
and support healthcare workers. “This requires leadership, joined-up
thinking, collaboration with policymakers and professional bodies,
good record keeping and HR and administrative processes that
reward quality, courage and honesty” Wolvaardt (2019).
a
a
References:
Overcoming obstacles to medication reporting. Pharmacy Times. (2016,
July 7). Retrieved January 12, 2022, from
https://www.pharmacytimes.com/
Parker, J., & Davies, B. (2020). No blame no gain? From a no blame
culture to a responsibility culture in medicine. Journal of Applied
Philosophy, 37(4), 646–660. Retrieved January 12, 2022, from
https://doi.org/10.1111/japp.12433.
S. Radhakrishna, Culture of blame in the National Health Service;
consequences and solutions, BJA: British Journal of Anaesthesia,
Volume 115, Issue 5, November 2015, Pages 653–655,
https://doi.org/10.1093/bja/aev152
Wolvaardt E. (2019). Blame does not keep patients safe. Community
eye health, 32(106), 36.
