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The Article in Brief
Nature of Blame in Patient Safety Incident Reports: Mixed Methods Analysis of a National Database
Andrew Carson-Stevens , and colleagues
Background A culture of blame and fear of retribution are recognized barriers to reporting patient safety incidents. The extent to which blame is assigned in patient safety incidents reports is unknown. This study set out to explore the nature of blame in family medicine incident reports.
What This Study Found When primary care staff members report patient safety incidents, they often attribute blame not to system failures but to the actions of individuals. Based on analysis of incident reports from the England and Wales National Reporting and Learning System, researchers found that healthcare professionals making incident reports attributed blame to a person in 45 percent of cases. In 36 percent of cases, reporters attributed fault to another person, while 2 percent of reporters took personal responsibility. Blame directed at others was more likely in discharge planning, communication, referrals, and diagnosis and assessment incidents, and was commonly associated with incidents where a complaint was anticipated.
Implications
- The high frequency of blame in primary care incident reports, the authors suggest, may reflect a health care culture that leads to blame and retribution. Improving patient safety through analysis of incident reports and identifying areas for learning will require a shift towards a culture that identifies system failures rather than blaming individuals, they conclude.