No-blame culture and the loss of the sense of sin

When I was last working in a hospital (probably this would be a good point at which to say that I am a pharmacist) I was informed that we operated under a 'no-blame culture'. The idea was that if mistakes were made then it was important to be honest about them so that steps could be taken to reduce the causes of error. The rationale is obvious: a dispensing error can have serious consequences, but if you are afraid that you (or one of your colleagues) might lose your job (or be sued) over it you are unlikely to report near-misses.

 

To a certain extent, this makes sense. By encouraging reporting of near-misses you can look at the systems involved and take steps to reduce errors. The pharmacy I worked in was, like most hospital pharmacies, badly laid-out (usually because clinical pharmacy services have expanded rapidly in the last 20 to 25 years and most hospitals are older than that) and extremely busy. We provided pharmacy services to the equivalent of 3 hospitals and effectively needed to employ one person full time just to answer the phone for non-clinical enquiries (not helped when the town council once made a typo in some communication and we started getting all their phone enquiries as well!). Errors are bound to creep in with a turnover of this size, and it is important that systems do not faciliate them. By reporting near-misses you can take steps such as keeping all your high-risk (to the patient) medicines such as methotrexate and warfarin on a separate shelf; separate out the 6 types of Sinemet tablets and the 5 variations on Epilim instead of sticking to strict alphabetical order; check, double-check and triple check everything, and stick massive posters in your fridge so that everyone is careful to quadruple check the insulin. Manufacturers usually help by making the packs different colours (although it must be confessed that some of them appear to be more concerned with brand identity than patient safety). So far, so good.

 

But a no-blame culture can only go so far. Sometimes an individual is at fault. It is easy to mix up your Sinemet, true, but it is easier still if you are talking whilst checking, thinking about something else, have already been shouted at by a consultant that morning, rely on your memory when you aren't really sure, or were out the night before. A chief pharmacist I know once went a delivered an official reprimand to a cupboard (in another department) because whoever had filled in the incident form had stated that the error was 'the fault of the cupboard for being untidy'.

 

Pope Pius XII said that the 'sin of the century is the loss of the sense of sin'. We are all too ready to blame systems, or cupboards, or the fact that we weren't concentrating on the consultant who shouted at us, or the workload. No-blame culture may help improve patient safety, but it doesn't address the need to take responsibility for our actions. Often, when a patient is waiting to go home, it is 'pharmacy' who is blamed for the fact that they can't leave yet. Leaving aside the many occasions when actually the doctor hasn't written the discharge prescription yet, and the times when the medicines have been dispensed and delivered to the ward and carefully locked in a the medicines cupboard, if 'pharmacy' as a whole is to blame, then whose fault is it? The chief pharmacist? The ward pharmacist? The ward technician? The dispensary manager? The pharmacy rececptionist? The administrator who approved too much annual leave at once?

 

Following the Francis report there have been complaints that no-one at Stafford hospital lost their job. This situation is not quite the same as a dispensing error which is a genuine mistake, because a long-term, widespread cover-up of abuse is not a mistake. But in both cases, somebody must be responsible; there is a perpetrator (or more than one). Whether or not that person should be sued, or sacked, or strung up is another issue. The point is that we all need to recognise that we aren't perfect, we make mistakes, we choose badly, sometimes deliberately; we need to look at ourselves and admit that some circumstances are not beyond our control. And we need to start doing this on the small scale because some of us have jobs where errors are a matter of life and death. Some of us don't, but stop and think about the last time you broke a plate and whether or not you said 'the plate broke' or the 'the plate got broken' rather than 'I dropped it'. The truth will set you free: trust me, I'm a pharmacist.