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.