Culture of Blame—An Ongoing Burden for Doctors and Patient Safety

Brborović, Ognjen; Brborović, Hana; Nola, Iskra Alexandra; Milošević, Milan

doi:10.3390/ijerph16234826

Cited by 20 publications

(24 citation statements)

References 13 publications

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“…First victims should be convinced that everything possible is being done to avoid a similar situation in the future. If the apology included a convince of systematic, organisational level learning from the AE, the professionals involved may feel supported when discussing AEs with patients, peers and managers [ 57 ]. From the literature reviewed changes appear needed at the individual, team, unit and organisational levels.…”

Section: Discussionmentioning

confidence: 99%

Action after Adverse Events in Healthcare: An Integrative Literature Review

Liukka

Steven

Vizcaya-Moreno

et al. 2020

IJERPH

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Adverse events are common in healthcare. Three types of victims of patient-related adverse events can be identified. The first type includes patients and their families, the second type includes healthcare professionals involved in an adverse event and the third type includes healthcare organisations in which an adverse event occurs. The purpose of this integrative review is to synthesise knowledge, theory and evidence regarding action after adverse events, based on literature published in the last ten years (2009–2018). In the studies critically evaluated (n = 25), key themes emerged relating to the first, second and third victim elements. The first victim elements comprise attention to revealing an adverse event, communication after an event, first victim support and complete apology. The second victim elements include second victim support types and services, coping strategies, professional changes after adverse events and learning about adverse event phenomena. The third victim elements consist of organisational action after adverse events, strategy, infrastructure and training and open communication about adverse events. There is a lack of comprehensive models for action after adverse events. This requires understanding of the phenomenon along with ambition to manage adverse events as a whole. When an adverse event is identified and a concern expressed, systematic damage preventing and ameliorating actions should be immediately launched. System-wide development is needed.

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Section: Discussionmentioning

confidence: 99%

Action after Adverse Events in Healthcare: An Integrative Literature Review

Liukka

Steven

Vizcaya-Moreno

et al. 2020

IJERPH

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“…A paradigmatic pivot to understand healthcare team as a collective entity and resilience as a favorable team quality, shifts the focus from the individuals who comprise a healthcare team to the organizational systems and processes that support the healthcare team. A shift from an organizational culture of blame to a culture of collegiality and support benefits patients and healthcare personnel [ 38 ].…”

Section: Methodsmentioning

confidence: 99%

A Qualitative Protocol to Examine Resilience Culture in Healthcare Teams during COVID-19

et al. 2021

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Resilience allows teams to function at their optimal capacity and skill level in times of uncertainty. The SARS-CoV-2 (COVID-19) pandemic created a perfect opportunity to study resilience culture during a time of limited healthcare team experience, protocols, and specific personal protective equipment (PPE) needed. Little is known about healthcare team resilience as a phenomenon; existing definitions and empiric referents do not capture the nature of healthcare team resilience, as the traditional focus has been placed on individual resilience. This qualitative research protocol provides the rationale and methodology to examine this phenomenon and builds a bridge between resilience engineering and individual resilience. The sample is composed of healthcare team members from the US. This research may add to the body of knowledge on resilience culture in healthcare teams during the COVID-19 pandemic. This qualitative research protocol paper outlines the rationale, objective, methods, and ethical considerations entailed in this research.

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“…In general, the experienced culture by the surveyors during the morbidity and mortality meetings, or the thought to culture varies. Although a morbidity and mortality meeting should ideally be a neutral root cause analysis debate, the name, blame and shame culture is frequently present during these meetings (29,30). The effectiveness and success of a debriefing is dependent on modifiable interpersonal factors, such as communication breakdowns (28).…”

Section: Interpretation Within the Context Of The Wider Literaturementioning

confidence: 99%

Second victim support structures in anaesthesia: a cross-sectional survey in Belgian anaesthesiologists

Nijs

Seys

Coppens

et al. 2021

International Journal for Quality in Health Care

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Background Anaesthesiologist are prone to patient safety situations after which second victim symptoms can occur. In international literature, a majority of these second victims indicated that they were emotionally affected in the aftermath of a patient safety incident and received little institutional support after these events. Methods Observational cross-sectional survey. Belgian anaesthesiologists and anaesthesiologists in training were contacted through e-mail from May 27th until July 15th 2020. Results In total 456 participants completed the online survey. 73.7% (n=336) of the participants encountered a patient safety incident during the last year of their medical practice. 80.9% (n=368) of respondents answered that they do discuss incidents with their colleagues. 18.0% (n=82) discuss all incidents. 19.3% (n=88) admit that these incidents are never discussed in their department. 15.4% of participants (n=70) experienced or thought that the culture is negative during these patient safety incident discussions. 17.3% (n=79) score the culture neutral. Anaesthesiologist who encountered a patient safety incident in the last years scored the support of their anaesthesia department a mean score of 1.59 (ranging from -10 to +10). A significant correlation (p<0.05) was found between the culture during the morbidity and mortality meetings, the support after the incidents and the perceived quality of the anaesthesia department. Conclusion Of the participating anaesthesiologist in Belgium, 80.9% discuss some patient safety incidents and 18.0% discuss all patient safety incidents as a normal part of their staff functioning with an experienced positive or neutral culture during these meetings in 84.6%. Psychological safety within the anaesthesiology departments is globally good, however could and should be optimized. This optimization process warrants further investigations in the future.

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Culture of Blame—An Ongoing Burden for Doctors and Patient Safety

Cited by 20 publications

References 13 publications

Action after Adverse Events in Healthcare: An Integrative Literature Review

Action after Adverse Events in Healthcare: An Integrative Literature Review

A Qualitative Protocol to Examine Resilience Culture in Healthcare Teams during COVID-19

Second victim support structures in anaesthesia: a cross-sectional survey in Belgian anaesthesiologists

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