When we see mistakes made by other people, particularly those that case damage, harm, or loss we have a choice. We can understand that in many cases, particularly in a health care system, the individual was probably trying hard to achieve a good outcome. Or, we can blame them for the undesirable outcome.
All too often, we choose blame. This includes in places that are committed to implementing and supporting a Just Culture. You will recall that a Just Culture is one that does not blame people for making mistakes that are well within the normal performance limits of people. We also should not blame or get frustrated with people who try to speak up about concerns they have related to the safety of the system they are working within. A reminder, a Just Culture does have a strong sense of accountability. Behaviors that are “blameworthy” are acted on quickly and aggressively.
The question remains, why do we continue to blame people who make mistakes, even in systems that believe in a Just Culture? I believe there are two main issues (and probably more….).
First is fear. There are some things people do that we believe require punishment and blame. If a nurse is perceived to have worked beyond the scope of her license, many nursing boards demand action and punishment. Sometimes it almost seams that it doesn’t matter that the nurse may have really been trying to do something good for a patient. Leaders in many hospitals are fearful that if they don’t act to punish or report the nurse, then they themselves will get in trouble. Another problem is that when a patient is harmed, many hospital leaders feel that they have to show a family that they are acting to punish someone. They are fearful that if they are not seen as taking action, then they will get in trouble. So fear, is a big barrier to having a blame free culture.
The second issue is a little more subtle. When we see people make a mistake it is much easier to blame someone and consider them lazy, sloppy, or even stupid. Since I am none of these things, then the mistake that was made by that other silly person won’t happen to me.
It is much more psychologically acceptable for me to consider that this horrible mistake, made by someone else, just won’t happen to me. Because here’s the thing, if I wake up one day and really accept (and I mean really accept!) that some mistakes will happen and they have very little to do with my work ethic, my brilliance, my passion, or my knowledge, then it might be really hard for me to walk into that hospital and try to do my job. Our denial may protect our psyche, but it won’t help us make our systems better and it will not help us create a Just Culture. Yet, it is this very culture, that if we could achieve it, it might be the thing that actually does prevent these errors that we both fear and deny.