No Shame in Blame (Sometimes)

Molly Rowe, for HealthLeaders Media, February 8, 2008

Leaders love to use lines like, "Mistakes are never one person's fault," or "Medical errors are the result of process breakdown, not people breakdown." But how do you tell that to the millions of people who suffer medical errors each year? Try boasting about your blame-free culture to the three patients at a Rhode Island hospital who experienced wrong-site brain surgery last year, or to actor Dennis Quaid, whose newborn twins were given 1,000 times the intended dosage of a blood thinner last November.

Don't get me wrong: I know that going blame-free has its advantages. Most organizations agree that near-miss reporting goes up and errors go down when information is anonymous and nonpunitive. But how does your reporting system identify threats to patient safety? How do you ensure that people are blamed when they should be--thereby ensuring that the same errors don't happen twice?

At Virginia Mason Medical Center in Seattle, CEO Gary Kaplan doesn't care for the term "blame-free." He's a believer in what he calls the "fair and just" culture--an environment in which people feel safe to report accidents and near misses but also understand that there will be accountability. Kaplan's system (which I wrote about in the December issue of HealthLeaders magazine) hasn't reduced the number of reports they receive--the number's actually gone up. But it ensures that the right people are held accountable and, when necessary, removed from a process when they might be endangering it.

Accountability can get even fuzzier when compensation is linked to patient safety. Organizations implement elaborate reporting processes but then base a portion of staff's annual pay increases on improving, say, hand washing. How do you convince nurses to report their non-washing colleagues if a portion of their paychecks depends on documented hand-washing compliance? One way to encourage more reporting is to make near-miss reporting itself a goal linked to compensation, as leaders at Sarasota Memorial have done. Sarasota's goal in 2007 was to increase error-reporting by 10 percent. (At year's end, reporting had gone up 7 percent.)

"Blame-free" shouldn't mean "not accountable." Healthcare leaders need to find a way to hold people accountable--when necessary--without scaring people into silence or creating an environment of finger-pointing. And reporting processes, although nonpunitive, should have a way of identifying risks--in the form of both process and people. This isn't an easy balance to strike, but it's an important one. Lives, after all, depend on it.

Molly Rowe is leadership editor with HealthLeaders magazine. She can be reached at
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