Today I was struck by the discussion on moving away from the “Blame and Shame” culture and moving towards a culture of transparency, reporting, and improvement for prevention of errors. I appreciated the examples given on how much more valuable it can be to look into an event and learn from it rather than focus on assigning fault and punitive measures. This can also help to avoid having a “second victim” who is harmed in medical errors – the provider.
I thought back to yesterday’s “Teeter Totter” game. The last group that volunteered to play had nearly all of their members on the teeter totter, but then when Brady stepped on the teeter totter tipped and the ‘patients’ were lost. I remember thinking that I bet he felt guilty; they were so close! But when we were debriefing from the game, that is not what I heard at all. I heard the team saying that they could all sense that something was wrong, and someone should have spoken up. They were thinking out loud about the potential causes of the tipping and how they might have prevented it, and not one of the comments blamed the last person to step on when it tipped. I think that group gave us a good example of how to move away from the culture of individual Blame and Shame to a systems improvement culture; one that can only work with full transparency.
There was a quote posted today from Sidney Dekker, which I think sums this thought up best: “We must ask what is responsible, not who is responsible. The aim of safety work is not to judge people for not doing things safely, but to try to understand why it made sense for people to do what they did… If it made sense to them, it will for others too.” This transparency creates understanding, learning, and allow improvement of the systems in place in order to prevent future mistakes – a must if we are to learn and improve the quality and safety of the care we provide.