Learning not blaming: patient safety initiatives

In the relentless effort to make progress on delivery of quality care and reduce patient safety incidents, a report entitled Learning not blaming has set out the Government’s response to three recent reports, which set out to amend specific concerns, only two of which will be highlighted here.  The culture of blame has been a continuing thorn in the side of many experts who have provided innovative solutions for the NHS and beyond, in response to patient safety incidents, poor care delivery or whistleblowers issues.  Many reviews and reports in the recent past have focused on failings and urged the NHS to learn from these events, creating a culture and systems which reduce risk. 

Incidents in patient care are generally poorly investigated within the system, as reported by Dr Durkin to the Public Administration Select Committee.¹ Investigative staff must be competent and confident, if local investigation is to be effective. Often there is very little consistency across a hospital, poor communication, low understanding of the commonly used root cause analysis or of managing the outcomes for the patient, their family or the healthcare professional involved. 

It is also very easy to identify the basis for errors or near misses in patient care and put the blame squarely at the door of a group of individuals or an individual in the team without looking at the latent or systemic factors which may have contributed to the error or near miss. This method of resolving the issue is to sanction the team or individual and move on, which misses many opportunities for prevention of a repeat error and of a warning to others that there is risk in the activity. If there is risk in the process, it has not been adapted to make it safer and may subsequently cause harm to others. In a high risk and complex industry such as healthcare, this is indeed a dangerous strategy.