“Learning from error, rather than seeking someone to blame, must be the priority in order to improve safety and quality.”
Not the words of the current Secretary of State (although he did speak about the need to Learn Not Blame, in various speeches at the end of last year), nor of the reports emerging from the mid-Staffs scandal (although Don Berwick did urge the NHS to “abandon blame as a tool”).
These words are from the recommendations of the report of the Public Inquiry into children’s heart surgery at the Bristol Royal Infirmary 1984-1995.
Blame in the NHS has been around a long time. Each of us will be familiar with everyday instances of blame being apportioned for things going wrong, near misses, and even when everything goes to plan but someone just doesn’t like the way it was done.
But why do we do it? And why has so little changed since 2001, when these words were written?
I recently took part in a BBC World Service programme, called “The Why Factor”, on blame. If you haven’t listened to it yet, you can catch up with it here. The other contributors to the programme shared some fascinating insights into blame, which are very directly applicable to the NHS.
Blame is a visceral defensive response, a “shield” that deflects pressure off when we are feeling attacked over something that has gone wrong. But it can also be a tool of attack by those in positions of power, and that has serious ramifications for the culture of an organisation, degrading it to a poisonous and toxic atmosphere.
But the blaming process does not take place in isolation. Publicly blaming others has actually been shown in studies to be socially contagious. When blame is modelled in a workplace, it spreads.
I have a very personal reason for caring about this. When I was an FY1, I was involved in the care of someone whose gentamicin levels were not adequately monitored. When I say involved, I prescribed at least one of the doses that shouldn’t have been given. It was an absolute “swiss cheese” scenario where all the holes lined up so that human error was not mitigated. The patient suffered organ failure and subsequently died.
But in my case, despite the family rightly making a complaint about the care their relative had received, I was not blamed individually. Instead, my consultant took responsibility, met the family, and found out what they wanted and needed – which was to understand how things had happened and how to ensure it didn’t happen again. So, at their request, the whole team involved in the patient’s care sat down with the family and went through everything. It was painful at the time – I’m sure more painful for the family – but I believe it led to some closure and it certainly led to changes within the hospital.
What I didn’t realise at the time – and have only come to realise in the last year – is that how I was treated, which was fairly, justly and without blame, is so rare within the NHS. I learnt from that awful tragedy, and it has shaped me as a doctor.
We must do better. So what can we do? By signing up to the Learn Not Blame campaign, you are already an advocate for change. But modelling the behaviours we want to see throughout the system is more powerful than we think. So the next time you find yourself slipping into the blame game, take a step back and think – can I break the chain of infection here? Can I find a different way to frame this? Instead, Sidney Dekker’s 3 questions are useful: who is hurt? What do they need? Whose responsibility is it to meet that need?