Beyond Blame

For years, the narrative surrounding human error in healthcare has painted a picture of individual flaws: a missed dose due to forgetfulness, a wrong diagnosis due to negligence and so on. Despite the human-centred foundations of the patient safety movement, we still see jarring reminders that the criminalisation of mistakes in healthcare is a continuing reality.

In the last issue, we introduced the idea of the ‘new view’ of human error. Recognising that errors are normal does not mean a reduction in individual accountability. Clinicians are still accountable for their actions but they are not solely responsible for the safety of care.

The new view emphasises that care is never provided in a vacuum and that all decisions (no matter how trivial or important) are tethered to context - the systems, processes, information and conditions within which the work is undertaken.

The new view of error is about understanding two things. First, understanding why actions taken by the individual made sense to them at the time (based on the information available to them) and second, to look beyond the error and to the systems that create the conditions for errors to occur.

Both these shifts put us in a better place to design more effective solutions to improve care. The apportioning of blame has no practical utility when it comes to learning from harm and improving safety.

Subscribe and never miss an issue, unlock additional resources at the end of each newsletter and get full access to previous content!

Moving Beyond Blame