Understanding the Blame Game: Why Are Voluntary Event Reporting Rates So Low?
Does a hospital’s blame culture — “nonpunitive response to error” according to researchers — influence medical error reporting rates?
In the 2 decades or so since physicians first sounded the alarm on the hazards of medical errors, the profession's tendency to blame individuals for mistakes has been consistently fingered as public health enemy number 1.
There's a certain logic to this: If the long arm of human resources — or, worse yet, the licensing board — promises to ensnare anyone who makes a mistake, the default instinct will be to deny, deny, deny. That's human nature, but it's also the basis for a culture of omertà that is optimized to bury the exact information that's necessary to improve patient safety.
It doesn't matter whether a physician is acknowledging their own misstep or calling out someone else's, snitches still get stitches, even if you're tattling on yourself. If that weren't enough, truth and reconciliation are even further complicated by the not-unreasonable sense that any admission of fault will invariably tilt the balance of institutional control in favor of the suits — administrators, actuaries, and other bureaucratic types — who would gladly risk adjust away physician judgment until it's nothing more than a passing memory. Because of all that, would-be whistleblowers find themselves caught between a rock and a disciplinary hard place: keep quiet and imperil patient care or speak up and endanger their careers, their colleagues, and maybe even their entire profession. Some choice. There's little doubt that, in terms of barriers to disclosure of medical errors, blame is easy to blame.
However, medicine's so-called blame culture may be more scapegoat than big bad wolf. In 2016, the Journal of Patient Safety published a study looking at the organizational factors that influence how frequently physicians report lapses in patient care.1 One of the possibilities considered was that the severity of a hospital's blame culture — or, as the authors put it, “nonpunitive response to error” — might influence reporting rates.
As it happens, not so much. Of all the factors examined by Jonathan D. Burlison, PhD, of St. Jude's Children's Research Hospital in Memphis, Tennessee, and colleagues, blame culture had the most variation between work units but also the smallest impact on error disclosure. When questioned about whether they'd be held personally accountable for their errors, hospital employee's beliefs were all over the place but had little effect on their likelihood of reporting an error. That's not great news for the pursuit of full and transparent error reporting. Changing the blame culture was touted as a big step forward, but it might actually be just a lateral move. So the search for an effective way to increase healthcare staff's willingness to report their mistakes soldiers on.
Psychologists face a similar sort of problem. The success of talk therapy requires something like radical honesty. Progress absolutely depends on the patient's willingness to cop to difficult truths. Granted, revealing a misstep to your therapist isn't likely to cost you a job or sully your professional reputation, but there's still real psychic cost to admitting a failure to someone else. In many other ways, therapy confessions are remarkably similar to medical error reporting: in both cases, the individual is the only possible source of critical information, there's an easy way out that comes with a lot less short-term hassle, and there's at least a partial abdication of personal and professional autonomy.
Yet, psychologists don't view the (non-)assignment of blame as a universal panacea. Instead, their aim is to construct an environment where the patient feels comfortable communicating anything and everything, regardless of who's at fault. This requires fostering what psychologists Harry T. Reis, PhD, and Phillip R. Shaver, PhD, refer to as intimacy.2 In the Reis and Shaver model, intimacy implies trust and emotional proximity but not romantic love or the other usual associations with intimate relationships. Instead, they describe intimacy as a component process where Party A's self-disclosure triggers feedback from Party B, which then elicits further disclosure from Party A, and on and on.
That feedback is paramount. People who receive appropriate and personalized responses to self-disclosures report stronger feelings of connectedness to the therapeutic process than those who get generic feedback or none at all.3 The resulting bump in intimacy presumably lays the foundation for further, deeper, self-disclosures. By this reckoning, intimacy isn't just an aspirational feeling, it's a tool that therapists actively use to induce difficult disclosures from their patients.
Self-disclosure in the setting of medical errors seems to adhere to roughly the same process. It might seem strange to contemplate the need for a hospital to create an environment of intimacy with its employees, but that may be precisely what's required. Physicians and nurses are ultimately individually responsible for deciding whether or not to file error documentation, but that choice is colored in part by what their employers do with that information. Unsurprisingly, the same study that downplayed the importance workplace blame culture found that the single strongest determinant of error self-reporting was whether staff was provided with feedback to disclosures.1 The association between high-quality feedback and submitting error reports was more than twice as strong as the link between reporting and the severity of the blame culture.
Just like in the therapist's office, the hospital's commitment to feedback — regardless of the nature of its blame culture — was the most powerful motivator encouraging people to tell the whole truth. It turns out that when it comes to reporting medical errors, hospital staff don't need absolution: They just need to know that they're being heard.
1. Burlison JD, Quillivan RR, Kath LM, et al. A multilevel analysis of US hospital patient safety culture relationships with perceptions of voluntary event reporting [published online November 3, 2016]. J Patient Saf. doi:10.1097/PTS.0000000000000336
2. Reis HT, Shaver P. Intimacy as an interpersonal process. In: Duck SW, Hay DF, Hobfoll SE, eds. Handbook of Personal Relationships: Theory, Research, and Interventions. pp 367-389. Oxford, England: John Wiley & Sons; 1988.
3. Haworth K. The Impact of Feedback in Response to Self-Disclosure on Social Connection: A Possible Analog Component Model of the Therapy Relationship [dissertation]. Milwaukee: University of Wisconsin; 2014.