Learn or Blame
“That patient you saw yesterday…”
We’ve all been there; your heart sinks, your spine stiffens, you are unsure if you can trust the person speaking to you, but you hope that they make it go away.
This post isn’t for those hearing those words; it’s for those saying those words and those who are partaking in an adverse patient safety event investigation.
Your clinical excellence, administrative station and even experience are beside the point. It’s your mindset that’s key.
The point is the recommendations – if you can’t point to how work-as-done itself has changed (ie: your recommendations are a virtual filing cabinet of PDFs asking people to try harder not to make mistakes), you probably don’t have the ‘no blame’ culture you think you do.
Learn or Blame: Cognitive Bias, Just Culture, and Adverse Events in Healthcare
We review two infamous live-TV errors to explore how our instinct to blame undermines learning after adverse events. Unpacking the cognitive biases of review that shape morbidity and mortality meetings, coronial cases and litigation: hindsight bias (“how could they not have seen this coming?”), outcome bias (judging decisions purely by how badly it turned out), the fundamental attribution error (blaming character rather than context), counterfactual thinking (“they should have…”, “failure to…”) and proximity bias (focusing only on the person at the sharp end, not the system at the blunt end).
Framed through Sidney Dekker’s view of human error, we contrast a retributive just culture (“which rule was broken and how do we punish it?”) with a restorative just culture (“who was harmed, what do they need, and how do we change the system?”). This leads to local rationality (what made sense to clinicians at the time given their goals, attention and knowledge), goal conflict, the efficiency–thoroughness trade-off, and the idea of second victims — all firmly grounded in everyday clinical work, hand hygiene “non-compliance”, EMR usability, and real incident review.
Key themes for clinicians
- You can either learn or blame after an incident—you can’t meaningfully do both.
- “Human error” should be the starting point of an investigation, never its conclusion.
- A true just culture assumes people came to work to do the right thing, and focuses on redesigning conditions, not punishing inevitable mistakes.
SMILE 2
Better Healthcare
Emergency physician FACEM, Melbourne Australia
One comment
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Hi George,
Worst problem I have is people forgetting. I am 65 and work very hard to remember stuff.
Daily emails to myself with to do list cc’g others immediately involved.
BLS/ALS/VT/AF/snake bite/sepsis/MI/CCF/asthma/FAST prompt charts, apps for pallimeds etc
SAR and ERPs in prominent places especially toilets. I ask people to do RMPS including pilots and drivers.
Still they forget. The ambo driver forgets to check the spare is replaced and inflated. Forgets to look and runs over staff members dog or patients dog. Grief. Non functional staff and raging patient.
Drug affected ambo driver. All orderlies on drugs. Don’t drug and alcohol test because we would have no ancillary staff. Would also lose a few nurses and docs. Happens about every 3 months.
Nurses forget and docs forget. Follow ups are forgot.
If I am working remote clinic this does not happen. Only in hospitals.
Theory says I have to make things important to them. Death and Disability make things important.
45 years of attending heli crashes+ investigation, MVAs, crashed sepsis’s, dead APHs M and M’s, amputated limbs, missed meloids ….I remember lots because it is important to me that my people do not die. I work in the north.
So many have died I cry writing this. The bronchiectasis deaths don’t worry me. They chose not to have treatment. They wanted to die on country. I will try to save them but tubing someone with bilat lung white outs is of no benefit though I do it anyway. It is important family sees I have done everything.
I throw the dead in the ambulance with nurse doing CPR. We stop once doors are closed and ambo moving and restart as we go through hospital doors. It is important that everyone sees we did our best. It is easy for me because they trust me and the nurses. They do not trust all doctors.
I am told by teachers to give 4mg per kg Ketamine. I know I must give only 1- 2. Aboriginal people are very sensitive to ketamine like they are to all sedatives and opioids. Asians as well. 4mg is only for big blokes on ice.
Tasering people on antipsychotics or antidepressants equals death.
Poly pharmacy on old people…you have seen all this too.
Help! What can we do to change things?
How do I get my people to be important to others? It is like talking to blank screens.
Regards,
Anthea Henwood