Clashing Cultures in Patient Safety: the "Blame Game" vs. the "Just Culture"

“Jaded Julie, you look very stylish in your coveralls, hard hat, safety glasses, and steel-toed shoes. What’s the event?”

“Well, Curmudge, you said that we were going to lay a foundation, so I felt that I should wear the appropriate personal protective equipment.”

“The foundation will be for our discussion of patient safety, Julie, and our computer shouldn’t be much of a hazard. But I’m delighted that your heart is in the right place. Let’s begin with a quotation from Dr. Lucian Leape, a well known guru of patient safety, ‘The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes.’(1) He seems to be saying that in a punitive culture, organizations try to punish people into not making mistakes.“(2)

“I presume that Dr. Leape is referring to the so-called ‘blame game’ in which every adverse event is considered a personal failure and triggers the ‘name, blame, and shame’ response. In that sort of atmosphere, it’s not surprising that people will hide any error that can be hidden. They’re not going to look for the root cause of the error, and it will probably happen again with a possibly more serious outcome.”

“Regrettably, Julie, in our society the ‘blame game’ seems like the natural thing to do. Professionals aren’t supposed to make mistakes, and it is assumed that when a mistake is made it’s because the person wasn’t good enough. Even the person making the mistake often feels that way. Our legal system compounds the problem with the threat of civil penalties (from malpractice suits) and in rare cases criminal penalties as well. It’s not surprising that if somebody makes a mistake, we either cover it up, refuse to admit it, or punish the person instead of asking, ’What gave rise to that mistake?’”(3)

“Curmudge, I have read that IHI uses a technique called the Global Trigger Tool to count mistakes. It’s used because only about 10 to 20 percent of errors are ever reported. Can you tell me more about it?”

“The Global Trigger Tool (4) uses retrospective reviews of randomly selected patient charts to locate and count adverse events (AEs). An AE is an injury or harm related to the delivery of care; it does not have to be the result of an error. A ‘near miss’ does not count because it, by definition, does not cause harm. Lists of ‘triggers’ are provided to serve as clues that an adverse event, from the viewpoint of the patient, has occurred.”

“This doesn’t sound much like Lean, Curmudge. Do you have an inexpert opinion?”

“You’re right as usual, Julie. Use of the trigger tool does not require a change of culture, identification of root cause, and use of the Deming cycle to develop countermeasures. Because it identifies AEs after the fact, there is no such thing as ‘stop the line.’ However, it does provide useful metrics to indicate if changes being made are improving the safety of care processes.”

“Okay, Curmudge. We have the metric, so how can we make the changes in patient care processes that it is going to measure?”

“The most effective change—yet the most difficult to achieve—is to abandon the punitive culture, i.e., the ‘blame game,’ and adopt the ‘just culture.’ We’ll start talking about that next week. I hope you’ll be here, Julie.”

“With bells on, Curmudge. I guess I won’t need the hard hat.”

Affinity’s Kaizen Curmudgeon

(1)http://www.mocps.org/resources/Marx%20Presentation%20Handouts%201.JC%201Day%20Training%20Slides%20PrintV2.pdf

(2)http://justculture.org Summer Edition, 2007

(3)http://www.webmm.ahrq.gov/perspectives.aspx November 2006. Conversation with Donald A. Norman

(4)http://ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Tools/IHIGlobalTriggerToolforMeasuringAEs.htm