Accountability and Learning from Failure

The single greatest impediment to error prevention is that we punish people for making mistakes.

Lucian Leape, in testimony on Veterans Affairs before the U.S. Congress, 1999

For most people, it is not hard to agree on the basics. Attributing adverse events to human error does little to improve the healthcare system. If we remove the error, or the individual who made the error, all we do is create an illusion of progress on safety. It denies the existence of system issues that gave rise to the error or its potential. It simply identi‹es a scapegoat, and it truncates learning anything meaningful from the event. Blame inhibits learning. And simple attributions of an adverse event to “human error” stop deeper investigation and hamper understanding (Dekker, 2006; Morath & Turnbull, 2005; Woods, Dekker, Cook, Johannesen, & Sarter, 2010). It is not dif‹cult to understand that a system of adverse event reporting and investigation needs to take a blameless approach if it wants to have the organization learn anything of value.