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Logo of bmjThis ArticleThe BMJ
BMJ. 2007 December 8; 335(7631): 1172.
PMCID: PMC2128675

Blame culture is still a problem in tackling patient safety

A culture of blame still stops healthcare professionals from reporting patient safety incidents, a Department of Health expert told a conference in London last week.

Jane Moore, director of healthcare quality at the department, said that the latest data from the Healthcare Commission, England’s healthcare watchdog, showed that harm to patients while in hospital was still a major problem.

In 2005-6 63% of organisations complied with all core safety standards, but this figure had fallen to 61% in 2006-7, the commission’s annual health check data showed. The commission also found that a similar number of independent sector providers had failed to meet national minimum standards on safety, Dr Moore told the conference on risk and patient safety, organised by the company Healthcare Events.

“We still blame individuals rather than look at what the causes of patient safety incidents are,” she said. “This means people still find it difficult to report [incidents].”

The data had shown some improvements. The number of staff who had seen an error in the past month fell over the period 2003 to 2006, for example, while the number of staff saying that the last error they had seen was reported had risen, she added.

“But more are saying that no action is taken to ensure that the incident does not happen again,” she said.

Government policy changes have been pushing safety up the agenda for the past nine years, she said, and policies for 2008 would continue to do that. The National Institute for Health and Clinical Excellence and the National Patient Safety Agency are producing safety guidance on cost effective ways to reduce harm to patients, which is expected to be published in December. Moreover, the role of the National Patient Safety Agency had been strengthened, Dr Moore said, and patient safety action teams at the level of strategic health authorities would provide local networks.

Communication failure was one of the main causes of error, said Michael Leonard, the physician lead for patient safety at Kaiser Permanente, one of the largest health maintenance organisations in the United States. Poor communication with clinicians over safety could create problems if managers wanted to engage them in change, he said.

“What happens is the conversation gets framed in the wrong way as . . . cookbook medicine. [The doctor thinks] you are treating me like an idiot and telling me what to do. What we should say is: ‘Here is the pattern of risk, here is where we know you will get in trouble,’” he explained.

However, a motion put to the conference that the ongoing revalidation of doctors and other healthcare professionals would improve patient safety in practice was defeated. The opposing argument, supported by a small majority of delegates, was that systems were to a large part responsible for risk and errors.

Gillian Hastings, who runs the charity the Health Foundation’s “safer patients” initiative, described some of the work of the initiative. It began in 2004 with four hospital trusts but expanded last year to include another 20. The four original hospitals were working as exemplars to the newcomers.

Ms Hastings said it was important for measurements to be meaningful to staff. She said that one of the new sites, the Taunton and Torbay Partnership, was achieving a low prevalence of methicillin resistant Staphylococcus aureus infection among its patients, a yardstick the government uses to measure trusts. But staff thought it would be better to measure the frequency of infections: “For the staff on the wards it can be easier to look at the time between infections—how many days between this and our last infection.”

One of the original four trusts was the Conwy and Denbighshire NHS Trust in Wales. It had introduced a range of devices to keep the momentum for improvement going in general wards. These included “safety weeks” and ward support teams.

Liz Baines, former patient safety coordinator at the trust, said, “Wards were struggling to introduce the changes associated with the safer patients initiative for a variety of reasons, such as a perceived lack of time, fear or reluctance to change, or being ‘change weary.’”

The support team and safety week ideas were first tested on one ward then reappraised and adapted before being retested and evaluated, she said.

Both ideas had led to use of a scoring system to prevent delays in the transfer of critically ill patients to intensive care, improve compliance with hand hygiene, increase the number of patients being referred to outreach teams, and reduce the numbers of cardiac arrests on general wards.

“One of the reasons the approach works is that you identify what [changes] you need to keep in a particular ward,” said Cathy Howe, head of clinical governance at the trust.


More details of the Risk and Patient Safety conference are at

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