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. 2017 Sep;15(5):455-461.
doi: 10.1370/afm.2123.

Nature of Blame in Patient Safety Incident Reports: Mixed Methods Analysis of a National Database

Jennifer Cooper  1 , Adrian Edwards  2 , Huw Williams  1 , Aziz Sheikh  3   4 , Gareth Parry  4   5 , Peter Hibbert  6 , Amy Butlin  1 , Liam Donaldson  7 , Andrew Carson-Stevens  8   6   9
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Nature of Blame in Patient Safety Incident Reports: Mixed Methods Analysis of a National Database

Jennifer Cooper et al. Ann Fam Med. 2017 Sep.

Abstract

Purpose: A culture of blame and fear of retribution are recognized barriers to reporting patient safety incidents. The extent of blame attribution in safety incident reports, which may reflect the underlying safety culture of health care systems, is unknown. This study set out to explore the nature of blame in family practice safety incident reports.

Methods: We characterized a random sample of family practice patient safety incident reports from the England and Wales National Reporting and Learning System. Reports were analyzed according to prespecified classification systems to describe the incident type, contributory factors, outcomes, and severity of harm. We developed a taxonomy of blame attribution, and we then used descriptive statistical analyses to identify the proportions of blame types and to explore associations between incident characteristics and one type of blame.

Results: Health care professionals making family practice incident reports attributed blame to a person in 45% of cases (n = 975 of 2,148; 95% CI, 43%-47%). In 36% of cases, those who reported the incidents attributed fault to another person, whereas 2% of those reporting acknowledged personal responsibility. Blame was commonly associated with incidents where a complaint was anticipated.

Conclusions: The high frequency of blame in these safety, incident reports may reflect a health care culture that leads to blame and retribution, rather than to identifying areas for learning and improvement, and a failure to appreciate the contribution of system factors in others' behavior. Successful improvement in patient safety through the analysis of incident reports is unlikely without achieving a blame-free culture.

Keywords: blame; blame culture; incident reporting; medical errors; patient safety; primary health care; risk management.

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Conflict of interest statement

Conflicts of interest: L.D. was the Chairman of the National Patient Safety Agency (NPSA) (2010–2012) and is currently the World Health Organization’s Patient Safety Envoy. P.H. has undertaken paid consultancy with Power Health Solutions (PHS), St Vincent’s Health Australia and for the Australian Commission on Safety and Quality in Health Care, all regarding incident reporting. A.B. obtained a Cardiff University Research Opportunities (CUROP) scholarship to undertake this work. There are no other conflicts of interest.

Figures

Figure 1
Figure 1
Types of blame.
See this image and copyright information in PMC

References

    1. Berwick D. A Promise to Learn – A Commitment to Act: Improving the Safety of Patients in England. London, England: Crown Publishing; 2013.
    1. Donaldson L. An Organisation With a Memory: Report of an Expert Group on Learning from Adverse Events in the NHS Chaired by the Chief Medical Officer. London, England: The Stationery Office; 2000.
    1. Barach P, Small SD. How the NHS can improve safety and learning. By learning free lessons from near misses. BMJ. 2000;320(7251): 1683–1684. - PMC - PubMed
    1. Firth-Cozens J. Barriers to incident reporting. Qual Saf Health Care. 2002;11(1):7. - PMC - PubMed
    1. Vincent C, Stanhope N, Crowley-Murphy M. Reasons for not reporting adverse incidents: an empirical study. J Eval Clin Pract. 1999;5(1): 13–21. - PubMed

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