Human Error and No Blame Culture

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2012 Health Care Service Group Conference
15 December 2011

Health Conference notes that it is not unusual that NHS and other health care staff are subject to disciplinary action as a consequence of the reporting of adverse incidents which have resulted from human error.

There is a pressing need to develop a process for dealing with adverse incidents that reserves disciplinary action for the minority of people who have acted maliciously. Human factors should be dealt with in a way that is less concerned with apportioning blame and more interested in learning from mistakes.

Conference further notes that excellent guidelines for such an approach exist, informed by the Clinical Human Factors Group and published by Patient Safety First. This guidance proposes that organisations need to promote the following:

a)An open culture in which staff feel comfortable to discuss patient safety issues with colleagues and senior management.

b)A culture of fairness, wherein staff, patients and carers are treated fairly and with empathy when they have been involved in a patient safety incident or have raised a safety issue.

c)An open and just reporting culture: wherein, crucially, staff are not blamed or punished when they report incidents. The reporting process itself should be easy.

d)A learning culture: wherein the organisation is committed to learning lessons from incidents, communicates these to colleagues, and remembers them for the future.

e)An informed culture: wherein the organisation learns from past experience and has the ability to identify and mitigate future incidents.

Conference calls on the Health Service Group Executive to:

1)Write to NHS employers seeking their view on the appropriateness of a no-blame culture in a context of the contribution of human error to adverse incidents.

2)Negotiate with NHS employers for the adoption of the Patient Safety First principles into the routine management of adverse incidents, so that human error is learnt from rather than individuals being punished.

3)Seek the support of professional regulatory bodies such as the Nursing and Midwifery Council & the Health Professions Council for a no-blame culture to be the standard approach to the investigation and management of such incidents.

In the meantime, branch officers and stewards can make use of the Patient Safety First resources when representing members who are caught up in disciplinary action following adverse incidents.