Improving Healthcare Team Performance by Bendaly Leslie;Bendaly Nicole;

Author:Bendaly, Leslie;Bendaly, Nicole;
Language: eng
Format: epub
Publisher: John Wiley & Sons, Incorporated
Published: 2012-09-17T00:00:00+00:00

Fear and Blame

Errors provide critical learning opportunities, but that learning will be stopped in its tracks in an environment where finger pointing, blame avoidance, and defensiveness are the norm. In this type of environment, events that represent exceptional opportunities to learn and improve care practice, service delivery, and patient safety are instead covered up or not talked about. Or, if they are discussed, the intent is to find fault rather than to prevent the event from happening again. In a blame culture, fear of punishment and judgment prevail and self-preservation takes priority over learning in the best interest of the patient and the team.

Much has been written and talked about in healthcare regarding the need to move from a blame culture to a blame-free or just culture. The purpose of reviewing an incident, harm event, or near miss should be to determine the cause from a system's perspective and identify ways of preventing the event from happening again, rather than finding individual fault.

Learning together from errors does not remove the personal accountability essential for individuals and the team to continue to develop and deliver the best care possible. Accountability, however, can only be achieved when teams approach errors and near misses by asking “what can we learn from this?” rather than “who can we blame for this?”

Marilyn Paul, an expert in organizational accountability, states that when organizations move from a culture of blame to one of accountability, they recognize first that “everyone may make mistakes or fall short of commitments,” and second that “becoming aware of our own errors or shortfalls, and viewing them as opportunities for learning and growth, enable us to be more successful in the future.”3 This can happen only when individuals trust that when they bring forward an error, near miss, or other learning opportunity, they will not be punished or judged negatively, but acknowledged for being transparent and taking ownership of putting patient safety and the quality of care first, and for helping themselves and the team to improve and learn together.

In 2010, the American Federal Aviation Administration (FAA) announced that the number of reported incidents rose 81 per cent since 2007, from 1,040 reported incidents in 2007 to 1,887 reported incidents in 2010. Upon first glance, this revelation might startle the average person and create concern; however, Diane Spitaliere, manager of media relations for the FAA, stated that passengers should not be alarmed by the increase in errors. Part of the increase, she explained, was due to better reporting methods implemented in 2008. The new method protects controllers from punishment for errors they voluntarily report. Since the non-punitive culture of error reporting went into effect, the FAA says it has received about 250 reports a week.4

“The FAA's mission is to keep air travelers safe,” Spitaliere said. “Over the past several years, the FAA has transitioned to a non-punitive error-reporting system at its air traffic facilities. This cultural change in safety reporting has produced a wealth of information to help the FAA identify potential risks in the system and take swift action to address them.

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