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Nature of blame in patient safety incident reports: mixed methods analysis of a national database

Cooper, Jennifer, Edwards, Adrian ORCID:, Williams, Huw, Sheikh, Aziz, Parry, Gareth, Hibbert, Peter, Butlin, Amy, Donaldson, Liam and Carson-Stevens, Andrew ORCID: 2017. Nature of blame in patient safety incident reports: mixed methods analysis of a national database. Annals of Family Medicine 15 (5) , pp. 455-461. 10.1370/afm.2123

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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.

Item Type: Article
Date Type: Publication
Status: Published
Schools: Medicine
Publisher: American Academy of Family Physicians (AAFP) / Annals of Family Medicine / HighWire
ISSN: 1544-1709
Date of First Compliant Deposit: 25 October 2017
Date of Acceptance: 30 April 2017
Last Modified: 03 May 2023 23:59

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