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

Jennifer Cooper; Adrian Edwards; Huw Williams; Aziz Sheikh; Gareth Parry; Peter Hibbert; Amy Butlin; Liam Donaldson; Andrew Carson-Stevens

doi:10.1370/afm.2123

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Figure 1
Types of blame.

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Table 1

Categories of Blame by Persons Reporting Safety Incidents

Blame Focus and Definition	Example
Acknowledging personal responsibility
Blames self	“Seen as temporary resident for an inguinal hernia awaiting operation. Was incarcerated (probably) and I acted on his history of this being reducible. I should have admitted him there and then and didn’t. No complaint by patient.”
Blames himself/herself for the incident
Blamed by another	“The patient was diagnosed as having a [rare type of cancer]. He had attended the surgery on and off since [date] with urinary symptoms which seemed to respond to antibiotics. He saw every clinical member of the practice and was examined but a thorough examination was impossible. He was referred for a possible hernia on [date] and to the urology department on [date]. He was seen by both specialties within a week and diagnosis was confirmed. There has been a comment made to the family by a consultant that we should have spotted it sooner.”
Describes a third party blaming him/her for the incident
Directed blame
Blames another	Example 1: “A terminally ill patient attended A&E in possible retention of urine. This patient has a syringe driver in situ with morphine and metoclopramide. The syringe driver was clearly labelled as per policy but despite this the doctor who saw the patient in A&E took the syringe driver down and left the patient without any analgesia or anti-sickness medication. As a result, the patient was in a lot of pain and was only given a small amount of oral analgesia after being in A&E for some hours. TOTALLY UNACCEPTABLE. Medication error/critical incident. Complete lack of knowledge demonstrated by the doctor. Inadequate assessment and lack of knowledge on behalf of the doctor, and failure to listen to the patient, as he did question why they were taking the syringe driver down.”
Blames another individual for the incident
Others blaming others	“Patient had an appointment with the doctor. Patient was in discomfort with problems swallowing and indigestion. This lady has complex co-morbidities. After a few days she felt very ill and thought it was the medication that had been prescribed on the day of her appointment. The patient contacted the practice but the practice would/could not provide an appointment that day or indeed the next day. The doctor eventually agreed to do another prescription without seeing her again (stemetil). When the patient went to collect the medication the pharmacist would not dispense the medication as it was not suitable for people with under active thyroid and it was for vertigo/nausea/vomiting. The patient could not raise this issue since the practice was then closed. The patient added that this is not the first time that something has happened like this.”
Describes another individual being blamed for the incident
Unknown blame	“Patient with rheumatoid arthritis on steroids was taken off bone protection medication for 1 year giving a ‘drug free holiday’ to reduce the incidence of atypical fracture (without a review date to re-start). She had been on this medication for 7 years. Stopping this medication was inappropriate.”
Blame identified but source unclear
No blame	“Computer system misinterpreted the directions for the dose of amiodarone and printed out 1/2 tablet daily instead of 1 1/2 stated on the prescription even though the patient’s computer record showed 1 1/2 daily as issued.”
No attribution of blame to a person

A&E = accident and emergency; GP = general practitioner; INR = international normalized ratio.

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Table 2

Numbers and Proportions of Blame Attribution (N=2,148 Reports)

Focus of Blame	Reports^a No. (%)
Acknowledges personal responsibility
Blames self	28 (1)
Blamed by another	13 (1)
Directed blame
Blames another	766 (36)
Others blaming others	128 (6)
Unknown blame	40 (2)
No blame	1,173 (55)

↵a Rounded to the nearest integer.

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Table 3

Likelihood of Directed Blame Attribution With Different Types of Safety Incidents Reported

Incident Type	Reports No.	Reports Containing Directed Blame No. (%)	OR (95% CI)^a
Discharge planning	33	27 (82)	6.5 (2.7–15.8)
Communication	36	25 (69)	3.3 (1.6–6.6)
Referral	170	106 (62)	2.5 (1.8–3.5)
Diagnosis and assessment	62	37 (60)	2.1 (1.3–3.6)
Medication	417	228 (54)	1.9 (1.6–2.4)
Administration	379	181 (48)	1.4 (1.1–1.7)
Treatment	77	37 (48)	1.3 (0.8–2.1)
Equipment provision	94	40 (43)	1.0 (0.7–1.6)
Other	68	27 (40)	0.9 (0.6–1.5)
Investigations	251	76 (30)	0.6 (0.4–0.8)
Record keeping and documentation	80	19 (24)	0.5 (0.3–0.7)
Vaccination	100	21 (21)	0.4 (0.2–0.6)
Pressure ulcer	381	70 (18)	0.3 (0.2–0.3)

OR=odds ratio.
↵a ORs for odds of directed blame when incident type is present vs incident type absent.

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Table 4

Directed Blame and Contributory Factors in Safety Incident Reports

Contributory Factor	Reports No.	Directed Blame No. (%)	OR (95% CI)^a
Staff factors (eg, staff knowledge, failure to follow protocols)	351	203 (58)	1.7 (1.3–2.3)
Organizational factors (eg, staffing level, continuity of care)	216	122 (56)	1.4 (1.0–1.9)
Patient factors (eg, frailty, language barrier)	263	100 (38)	0.5 (0.4–0.7)
Equipment factors (eg, faulty or missing equipment)	35	8 (29)	0.3 (0.1–0.6)
No contributory factors reported	1,283	461 (36)	…
All reports	2,148	894 (42)	…

OR=odds ratio.
↵a Comparing odds of directed blame where contributory factor is present vs odds of blame where an alternative contributory factor is present.

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Table 5

Directed Blame and Severity of Harm in Safety Incident Reports

Variable	Reports No.	Directed Blame No. (%)	OR (95% CI)^a
No harm	271	145 (54)	1.0
Mild	1,028	435 (42)	0.6 (0.6–0.9)
Moderate	149	66 (44)	0.7 (0.7–1.4)
Severe	21	2 (10)	0.1 (0.0–0.5)
Death	6	5 (83)	4.4 (0.6–46.2)
Patient out-come not reported	673	241 (36)	…
Total reports	2,148	894 (42)	…

ICPS = International Classification for Patient Safety; OR = odds ratio; WHO=World Health Organization.
Note: Based on WHO ICPS harm level classification.
↵a Odds of directed blame for each level of harm compared with odds of blame for no harm.

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.