Unfortunately, the health sector is not faultless, and multi mistakes can happen.
What medical errors means :
Medical errors can be characterized as deviations from standard practice with negative results(Espin, Levinson, Regehr, Baker, & Lingard, 2006).
patient safety incident characterized as “any unintended or startling episode that could have hurt or harmed a patient during care ”
New studies of medical errors have estimated errors may reach as many as 251,000 deaths annually in the United States (Andorsen JG, 2017).
Due to the high event of accuse culture in the hosipitals that shield workers from announcing mistakes and giving criticism or proposals (Kaissi, 2006).
This all prompts less openness and less organizational learning, which implies similar mistakes will be made again and again.
(An organization not to be open about mistakes, suggestions and ideas, because of a fear of being separately considered responsible for them). ( Khatri et al., 2009).
It inhibits creativity by preventing the staff from building new thoughts, which prevent organizational learning as well (Goh & Richards, 1997; Khatri, Brown, & Hicks, 2009).
Not only patient safety in risk because of this, but also health care providers will feel the outcomes too.
The onset of blame culture can be ahead of schedule as during the training stage, since this instruction is regularly for the most part centered around increasing performance instead of expanding security or organizational learning.
Reason of blame culture :
Due to the huge increase of individual autonomy that help in expanding the blame culture (Reason, 1997).
the point of interest is on the only who brought on the incident rather than the system that might be unsafe.
personnel attempt to guard themselves and blame others, and hence their attention shifts from patient protection to needles sections like office work (Khatri et al., 2009).
presenting compassionate care turns into tougher with a excessive incidence of blame culture (Crawford, Brown, Kvangarsnes & Gilbert, 2014).
enhancing the occurrence of defensive medicine (Catino, 2009).
because of this healthcare personnel pick no longer to carry out risky techniques or perform useless processes..
Defensive medicine can endanger and damage patients, as well as icrease healthcare expenses exceedingly(Catino, 2009).
Blame generate biases.
Blame has an emotional context.
Blame can hurt
described as a supportive environment wherein concerns or conflict can be expressed and mistakes admitted without struggling ridicule or punishment.
on this culture , event are identified, record and investigated, to accurate the system.
First, it determine a set of organizational characteristic that perpetuate a blame culture and those that evolve a just culture in health care.
Second, it proposes that human resource (HR) management capabilities play an important function in a health care organization’s conversion from a blame culture to a just culture.
1- control-based management.
The blame culture is greater widespread in the control-based management and the just culture is greater common in the commitment-based management.
employees in the control-based environment follow instructions and orders and do just what they are told about .
in a control based organization, the hierarchy is tall and communication is poor from top–down, employee receive the order from the top manager .
a control based may reach a satisfactory level of overall performance, however it cannot attain the high level needed for a just culture.
The control-based management approach causes the low motivation and generates poor emotional energy.
the control-based management effect the system inflexibility and reduce teamwork and collaboration between the employees
Commitment-Based Management has two advantages :
the learning effect, the commitment based management increases learning from mistakes by encourage a ”virtuous cycle” in which organizational members account all the medical errors and look for extensively for their reasons in an open and trusting environment .
In Commitment-Based Management hierarchy is flat .
generates excessive motivation in the workforce and positive emotions .Thus, it enhances improving of care and patient safety by improving the confidence of the workforce.
human are absolutely committed to the organization, and they commit to the organization when they are trusted and allowed to work independent .
the HR function has to play a significant in managing organizational culture, change, and learning in health care organizations(Khatri, 2006; Khatri,Wells,et al.,2006;Vestal etal.,1997).
To be able to transfer an organization from a blame culture to a just culture need an HR function of the organization to have HR capabilities (Khatri, 2006; Vestal et al., 1997).
Greater employee knowledge and skills are needed in such services because unpredictability during the service encounter produce a need for employees who can make continuous decisions. Employee need the ”ability and authority to achieve results for customers”
to move from a blame culture to a just culture, health care organizations first need to move away from an overly compliance-driven, regulated management system to a commitment-based management system that motivate employee contribution and interest in decision making.
if we are necessarily suggesting that a control-based management type is always bad. This is not correct .
carried out the control-based management is likely to lead to higher organizational performance than a poorly perform commitment-based management.
There is enough space and stimulation to record event or calamities to control and/or the official reporting system (Ehrich, 2006).
There aren’t any negative effect standing in the way of reporting and employees are even stimulated to evaluation the incidents (Ehrich, 2006).
Underreporting is the norm, and it has been anticipated that reporting systems detect only 10% of unlucky events in hospitals. So, underreporting represents a major lost opportunity to understand errors and prevent harm.
The patient safety is based totally on the assumption that patient safety incidents are largely the result of poorly designed systems.
to identify the types of statements of attributed blame made within the reports and to connect them to the nature of the episode.
The reports were analyzed in line with prespecified categorizing systems to explain the:
Severity of damage .
They developed a taxonomy of blame attribution, and they then used descriptive statistical analyses.
To identify the relationship of blame types and to investigate associations between it event feature and one type of blame.
effective development in patient safety through the analysis of event reports is unlikely without accomplishing a blame-free culture.
The amplification of the process of looking for someone to blame is neither in the interests of patients, nor staff, nor of making health care safer.