Blame or learning?
On a recent course a consultant clinician told me of a colleague who had made a genuine error and patient harm had resulted.
The clinician went to their own management and told the tale against themself with the intention of sharing learning and stopping the identical thing happening again.
The treatment they received can be described in a couple of words - blame and humiliation.
Result - never again will that sensible honest professional ever confess.
The more tragic result is the loss of such a powerful educational lesson.
The real lesson from high reliability professions is to seek to learn from every possible opportunity.
We get told these tales all the time on courses, where we have explained how errors occur and what the barriers are everyday to open communication and defeating inappropriate hierarchy.
Healthcare professionals all seem to have horror stories of their own. Some where they have committed the error, some when they have failed to intervene. There is so much learning out there. The vast majority appear to be human factors related. What a wasted resource.
With training, management and teams can learn to shift focus towards a learning culture rather than blame. The result? An open reporting culture, with better communication and less repeated mistakes.