Healthcare providers need to learn from mistakes rather than simply appointing blame

Incident investigators should also take into account the environment and pressures staff are working under.

Matt Bodell
6 June 2019
Finger Pointing Blame

Providers need to focus on learning lessons from mistakes and preventing errors.

It is important for healthcare providers to focus on learning lessons from mistakes and preventing them in the future rather than simply looking to assign blame, says the Royal College of Nursing.

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The comments come following the publication of a landmark review into gross negligence manslaughter and culpable homicide by the General Medical Council (GMC).

The review was undertaken in response to the treatment of Dr Hadiza Bawa-Garba and Nurse Isabel Amaro who were convicted by the courts of gross negligence manslaughter following the death of Jack Adcock.

It calls for investigators to standardise their approach and take into account the environment and pressures staff are working under. Legal protection for reflective notes and the use of independent medical advisors to quickly determine if a criminal investigation is necessary are also recommended.

Echoing the findings of previous reports, the review highlights that black and ethnic minority backgrounds are more prone to complaints and investigation.

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Impossible situations.

A spokesperson for the Royal College of Nursing said:  “Healthcare needs to be viewed as a safety-critical industry, with a focus on learning lessons from mistakes and preventing errors in the future rather than apportioning blame.

“Taking the approach we witnessed in the Dr Bawa-Garba case risks creating an environment in which clinical staff feel afraid to come forward for fear of censure.  In particular, we support the findings related to addressing the over-representation of black and ethnic minority staff in this type of criminal case.”

“There is nothing worse for a healthcare professional than knowing you’ve made a mistake or weren’t able to give the best possible care to a patient.  Focusing solely on individual blame ignores wider lessons, and risks repeating the mistakes of the past.

“Chronic nurse understaffing has left thousands of healthcare professionals doing the best they can in impossible situations, and simply blaming them when things go wrong, rather than addressing the wider issues, is not the answer.

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Tragedy and unspeakable distress.

Dr Chaand Nagpaul, Council Chair for the British Medical Association, said: “When an error is made in a medical environment that is so serious that a patient loses their life, though incredibly rare, it is a tragedy, causing unspeakable distress to the person’s family and loved ones, as well as to the health professionals involved.

“This review’s recommendation for the appropriate authority to scrutinise the environments that doctors find themselves working in is a positive one. The BMA has repeatedly called for systemic pressures to be explored and recognised when errors occur.”

“That doctors from black and ethnic minority communities are more vulnerable to complaints and investigation, and are disproportionately represented in fitness-to-practise proceedings, is another concern that the BMA has long been raising, and we welcome this review’s work and recommendations in this area.”

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