The student who made the pipetting error believed that she had added patient plasma to the correct tubes and never did explicitly admit making an error. The supervising technologist admitted that she should have noticed the abnormal test volume but did not.

  1. Is this a typical first reaction when people make errors?
  2. Which approach to error management facilitates staff actively detecting errors and admitting to them?
  3. What is the challenge of a blame-free environment?
  1. In some ways the student's response is expected since when we make errors we do not realize that we are doing so. Obviously, if we knew that we were making an error, we would not do it! Also, students sometimes initially react defensively, especially if they fear being blamed and disciplined.

    The technologist's response reflects a mature approach to accepting responsibility for one's actions. Often even experienced staff will shift blame to others or to circumstances. It is rare to see someone respond when an error is made by raising a hand and shouting "I did it!"

  2. A blame-free approach that focuses on systems and processes, not individuals, facilitates error management and quality improvement. Few staff are willing to come forward and admit to an error when they face disciplinary action.
  3. The challenge of a blame-free environment is that organizations must balance the need to promote error reporting with the need to discipline staff who violate rules:

    "From a system safety perspective, our concern is whether it is more beneficial to punish the negligent health care provider in hopes that she pays better attention to avoid future punitive sanction, or whether it is more beneficial to allow the negligent provider to come forward so that the system may learn from the erring individual?" Source:

    Marx D. Patient safety and the “just culture”: A primer for health care executives