A ‘No Blame’ Culture Misunderstood

26Jun2018

Two true stories:

1.              A doctor administered the wrong drug in error and a patient died. 

2.              A helicopter pilot put the wrong fuel in the fuel tank and the engine stopped mid-air.

Fortunately, he was able to land the helicopter safely, and no one died.

The doctor was administering an anaesthetic drug, and had two syringes on his tray, both of which were filled with different drugs. He picked up the wrong one, injected the patient, and moments later realised his error. An emergency was declared and everything was done to reverse the effect of the drug, but the patient died.

The helicopter pilot was shown a glass of the fuel to be put in the tank so that he could smell it and see its colour. However, after confirming it was the correct fuel, somehow the wrong fuel was added to the tank. No one knows where the error lay.

What is interesting, though perhaps not surprising, is that, in both cases, the individuals involved took full responsibility for their error. It did not occur to either of them that the ‘blame’ lay anywhere else.

A modern synthesis of these two incidents is that both individuals at the sharp end should not bear the entire burden of blame; others hold responsibility as well. However, the pendulum swings too far, and reaches a point where these incidents are put forward as good arguments for having a ‘no blame’ culture. This is wrong. The two individuals do bear a certain responsibility, but the fact they were able to make these errors lies with other deeper and more complex aspects of the incidents. To put it more bluntly, the fundamental ‘blame’ lies elsewhere, in the domain of those who designed the procedures. They are equally at fault, or perhaps even more so. Who thought up the procedures that made it so easy for these errors to occur, and had the authority to implement them? 

There are, of course, other examples of similar incidents. Every year tens of thousands of drivers in the UK put the wrong fuel in their cars. The cost to the country runs to millions of pounds, wasted time, and the environmental problem of disposal of the mixed fuel. Are they to ‘blame’ for this obvious mistake? Well, yes, but that’s too narrow an approach. So where does the real blame lie? Surely it should be with a higher authority – at governmental or manufacturer level. After all, it would be so easy to have pump nozzles designed to fit only the correct tank filler opening. This would then create a condition where the potential for ‘human error’ is obviated.

And so it is with the doctor and the helicopter pilot. They are not without blame, but the real culprits are those in higher places, who did not foresee the possible failures in each of these procedures and build in appropriate barriers and defences to prevent such dreadful outcomes. They are really the ones ‘to blame’.

But let us remove the word ‘blame’ altogether and replace it with two much better words: ACCOUNTABILITY and RESPONSIBILITY. ‘Blame’ carries with it notions of punishment and condemnation. The alternatives remove this negativity and allow for more positive outcomes based on learning and proactivity.

We are all accountable and responsible for our own safety and that of others.

 

 

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