That’s the title of an article by Meadley et al that appears in the journal ‘Paramedicine’ (full citation below). The article says:
An essential first step for health organisations, including those who employ paramedics, is to acknowledge that most errors are due to system breakdowns rather than individual transgressions… most errors are ‘… committed by competent and committed caregivers [which are] best dealt with by focusing on improving systems rather than people’.
From there they argue that institutions such as jurisdictional ambulance services need to be build a culture where paramedics can report patient safety incidents and near misses with confidence that the service will look to identify systems issues rather than attribute personal blame. The authors say:
Any review of patient safety incidents should be underpinned by key patient safety concepts such as ‘systems thinking’ and an open ‘just’ culture. A mature review process must also be fair, focusing on systems and not individuals, and provide support to both staff and patients involved. Furthermore, the analysis of any event should focus on ‘what happened?’, ‘why did it happen?’ and ‘how could it be prevented from occurring again?’…
Central to this work is a patient safety incident management system that is non-punitive and, as such, moves away from a ‘culture of blame’ allowing a culture of self-reporting to thrive.
Not surprisingly these demands to move away from the blame culture are not new and have been led by authors such as James Reason (see for example The Human Contribution: Unsafe Acts, Accidents and Heroic Recoveries (2008, Routledge)) and Sidney Dekker (see for example Just Culture: Balancing Safety and Accountability (2nd ed 2012, Routledge) and The Field Guide to Understanding ‘Human Error’ (3rd ed, 2014, Routledge)). Attempts to move away from blame culture have been developed in medicine with the ‘open disclosure’ approach to patient safety incidents (see Australian Commission on Safety and Quality in Health Care, Open Disclosure, https://www.safetyandquality.gov.au/our-work/clinical-governance/open-disclosure).
Professor Steve Dovers and I also did work on the need to move away from a blame culture when reviewing the response to disasters – see:
- Restorative inquiries and natural disasters – symposium report (Bushfire and Natural Hazards CRC, 2019);
- Learning for emergency services: looking for a new approach (Bushfire and Natural Hazards CRC, 2017);
- ‘Reviewing high-risk and high-consequence decisions: finding a safer way’ (2017) 32(4) Australian Journal of Emergency Management 26-29; and
- ‘Learning lessons from disasters: alternatives to Royal Commissions and other quasi-judicial inquiries‘, (2015) 74(4) Australian Journal of Public Administration 495–508
Given my own work it is no surprise that I find the work of Meadley et al persuasive.
The problem, as I see it, is that the paramedic regulator – the Paramedicine Board – has limited ability to also support a ‘just culture’. The regulation of health practitioners is meant to be protective rather than punitive, but it is limited to health practitioners not health services. The Paramedicine Board can consider whether a practitioner’s conduct meets expected standards and can impose conditions on a practitioner’s registration. The Board (and the relevant Tribunal in more serious cases) cannot make similar orders on the institution in which the individual paramedic or health practitioner had to work.
To be fair, the tests for professional performance under the Health Practitioner Regulation National law require a paramedic’s conduct to be assessed against what could or should be expected by a similar practitioner in the same circumstances which should include the same institutional circumstances, but a Committee or Tribunal will have limited ability to explore how institutional failures and more importantly institutional culture contributed to an incident that manifests as a failure in delivery of appropriate care to a single patient.
The consequences of something other than a ‘just culture’ can be devastating for both the patient and practitioner – see:
- Professional discipline after serious criminal conviction – lessons from the UK (January 29, 2018);
- Australian commentary on the case involving Dr Hadiza Bawa-Garba (February 4, 2018); and
- UK doctor successful in appeal against decision to remove her name from the register following manslaughter conviction (August 14, 2018).
That is not to say there are no quality assurance mechanisms applied to health care institutions including through accreditation and licensing. People can complain to health complaints bodies – such as the Health Care Complaints Commission in NSW or the Health Ombudsman in Queensland – about the service provided by organisations as well as by practitioners.
Even so it remains the case that regulation remains focussed on the practitioner level. True learning will only come when organisations reviewing patient safety standards can look with equal focus at both the institutional and individual performance. These are issues that the Paramedic Observer, Ray Bange has written on – see Holding ambulance services, and their managers to account (October 12, 2022).
Conclusion
Meadley et al’s argument makes a useful contribution to the broader ‘just cause’ literature and one can hope that it is something organisations and health complaints bodies are already thinking about. There is still a long way to go however before regulators can, and the community will accept that when something goes wrong, someone must be to blame and someone must be held account.
Full citation:
Meadley B, Humar M, Salathiel R, McManamny T. Advancing paramedicine: Error, accountability and patient safety. Paramedicine. 2023;0(0). https://journals.sagepub.com/doi/10.1177/27536386231189006
Disclosure:
I am an associate editor for the journal Paramedicine. I did not review or contribute to this article before publication.
This blog is made possible with generous financial support from the Australasian College of Paramedicine, the Australian Paramedics Association (NSW), Natural Hazards Research Australia, NSW Rural Fire Service Association and the NSW SES Volunteers Association. I am responsible for the content in this post including any errors or omissions. Any opinions expressed are mine, and do not necessarily reflect the opinion or understanding of the donors.
Australian Emergency Law 
It is indeed a bit of a difficult spot.
If clinicians are making errors, I would hope the clinicians would be reporting these errors no matter how big or small. However, if there is a punitive culture that punishes the clinician rather than supports them. We know the individual is less likely to report an incident if there are punitive measures attached – ie ‘I may lose my job, so I won’t report’ or ‘I’ve made a number of errors recently, I am going to be suspended’. We need to avoid this culture where possible.
I think there needs to be a balance between just, but that also stops with ‘unreasonable’ or negligent practices. There has to be a learning event if an error has occurred to make sure that error does not occur in the future.