RT Journal Article
SR Electronic
T1 Nature of Blame in Patient Safety Incident Reports: Mixed Methods Analysis of a National Database
JF The Annals of Family Medicine
JO Ann Fam Med
FD American Academy of Family Physicians
SP 455
OP 461
DO 10.1370/afm.2123
VO 15
IS 5
A1 Jennifer Cooper
A1 Adrian Edwards
A1 Huw Williams
A1 Aziz Sheikh
A1 Gareth Parry
A1 Peter Hibbert
A1 Amy Butlin
A1 Liam Donaldson
A1 Andrew Carson-Stevens
YR 2017
UL http://www.annfammed.org/content/15/5/455.abstract
AB 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.