Monday, 16 December 2013

It's not my fault, it's the drifting, complex system.

One of the explanations provided by people for not embracing a systems-based approach to incident investigation is that it allows the "bad" individual to escape punishment.

In their book "Crisis Management in Acute Care Settings", St Pierre, Hofinger, Buerschaper and Simon state:
"Misapplication of (Reason's) Swiss-cheese model can shift the blame backward from a 'blame-the-person' culture to a 'blame the system' culture. In its extremes, actors at the sharp end may be exculpated from responsibility"
The concern is that some individuals (Robert Wachter labels them the "incompetent, intoxicated or habitually careless clinicians or those unwilling to follow reasonable safety rules and standards") will not be held accountable. These deviants will blame "the system" for not stopping them earlier or not making it clear enough what a violation was or not training them better. Wachter's 2012 paper "Personal accountability in healthcare: searching for the right balance" argues that lines must be drawn to distinguish simple human mistakes from sub-standard performance.

In his book "Managing the risks of organisational accidents" James Reason also calls for the drawing of a line "between acceptable and unacceptable behaviour" and calls for the replacement of a "no-blame culture" with a "just culture".

Drawing the line

A number of people/organisations have proposed "line-drawing" mechanisms:

  • David Marx: who says we must differentiate between "human error" (a slip/lapse), "at-risk behaviour" (wilful shortcuts) and "reckless behaviour" (substantial and unjustifiable risk)
  • The English National Patient Safety Agency (NPSA): their decision tree asks us to carry out 4 tests (deliberate harm, incapacity, foresight, substitution)
  • Leonard and Frankel: they consider 4 questions (impairment, deliberately unsafe, substitution, prior history)
  • Reason (see figure)

James Reason's decision tree (although it looks more like a hedge)

Not "Where?" but "Who?"

In his book "Just Culture", Sidney Dekker argues very convincingly that the line is arbitrary and that the definitions are fuzzy. Without being able to travel back in time and then read the mind of the individual who was at the sharp end of the error how can we be 100% sure that an act was intended or not? Instead Dekker argues that the argument should centre around who gets to draw the line(s): peers, regulators or prosecutors.

Abolishing retrospective blame

One idea that may inform the argument is that it may not be sensible, effective or just to attempt to make "someone" accountable in retrospect once an error has been committed and a patient harmed. Therefore if errors are discovered as part of an adverse event analysis then these should not be used to "blame" individuals. However, as a corollary, it may be appropriate to make people accountable for their current and future behaviour. It is therefore just as important to have systems in place to check and enforce correct behaviours as it is to be able to analyse past events.

As an example, consider the surgical pause as described in the WHO safety checklist. It makes little sense to blame a person or a team for not completing the pause correctly in retrospect once an error has been reported. It is much better to seek an active safety culture which would pick up the fact that the pause is not being done correctly before a patient has been harmed. It is this proactive approach to safety which is still missing in many places.

This post concludes with Don Berwick's thoughts:

"Blame and punishment have no productive role in the scientifically proper pursuit of safety."


  • Berwick, D. Quoted at:
  • Decker, S. Just Culture. Farnham, UK: Ashgate Publishing Ltd. 2007.
  • Leonard MW, Frankel A. The path to safe and reliable healthcare. Patient Educ Couns 2010;80:288–92.
  • NPSA
  • Reason, JT. Managing the risks of organisational accidents. Aldershot, UK: Ashgate Publishing Co. 1997.  (Decision tree from:
  • Wachter, RM. Personal accountability in healthcare: searching for the right balance. BMJ Qual Saf 2012;0:1–5.
  • Wachter RM, Pronovost PJ. Balancing "no blame" with accountability in patient safety. N Engl J Med. 2009;361:1401-1406 

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