Firstly, it is often the best people who make the worst mistakes-error is not the monopoly of an unfortunate few. As a result, two important features of human error tend to be overlooked. 5 Engineering a just culture is an essential early step in creating a safe culture.Īnother serious weakness of the person approach is that by focusing on the individual origins of error it isolates unsafe acts from their system context. 4 Trust is a key element of a reporting culture and this, in turn, requires the existence of a just culture-one possessing a collective understanding of where the line should be drawn between blameless and blameworthy actions. The complete absence of such a reporting culture within the Soviet Union contributed crucially to the Chernobyl disaster. 3 Without a detailed analysis of mishaps, incidents, near misses, and “free lessons,” we have no way of uncovering recurrent error traps or of knowing where the “edge” is until we fall over it. 2 Effective risk management depends crucially on establishing a reporting culture. In aviation maintenance-a hands-on activity similar to medical practice in many respects-some 90% of quality lapses were judged as blameless. Indeed, continued adherence to this approach is likely to thwart the development of safer healthcare institutions.Īlthough some unsafe acts in any sphere are egregious, the vast majority are not.
Nevertheless, the person approach has serious shortcomings and is ill suited to the medical domain. It is also legally more convenient, at least in Britain. Seeking as far as possible to uncouple a person's unsafe acts from any institutional responsibility is clearly in the interests of managers. If something goes wrong, it seems obvious that an individual (or group of individuals) must have been responsible.
#The reason free
People are viewed as free agents capable of choosing between safe and unsafe modes of behaviour. Blaming individuals is emotionally more satisfying than targeting institutions. From some perspectives it has much to commend it. The person approach remains the dominant tradition in medicine, as elsewhere.
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