Blaming Blame (September 2018)

In the two decades or so since doctors first sounded the alarm on the hazards of medical errors, the profession’s tendency to blame individuals for mistakes has been consistently fingered as public health enemy number one. There’s a certain logic to this. If the long arm of human resources (or, worse yet, the licensing board) promises to ensnare anyone who makes a mistake, the default instinct will be to deny, deny, deny. That’s human nature — but it’s also the basis for a culture of omertà that’s optimized to bury the exact information that’s necessary to improve patient safety. It doesn’t matter whether you’re acknowledging your own misstep or calling out someone else’s; snitches still get stitches, even if you’re tattling on yourself. And if that weren’t enough, truth and reconciliation are even further complicated by the not-unreasonable sense that any admission of fault will invariably tilt the balance of institutional control in favor of the suits — administrators, actuaries and other bureaucratic types — who would gladly risk-adjust away physician judgment until it’s nothing more than a passing memory. Because of all that, would-be whistleblowers find themselves caught between a rock and disciplinary hearing: keep quiet and imperil patient care, or speak up and endanger their careers, colleagues and maybe even entire profession. Some choice. There’s little doubt that, in terms of barriers to disclosure of medical errors, blame is easy to blame.

But medicine’s so-called blame culture may be more scapegoat than big bad wolf. A couple of years ago the Journal of Patient Safety published a study looking at the organizational factors that influence how frequently doctors report lapses in patient care [1]. One of the possibilities considered was that the severity of a hospital’s blame culture — or, as they put it, “nonpunitive response to error” — might influence reporting rates. As it happens, not so much. Out of all the factors the researchers tested, blame culture had the most variation between work units, but also the smallest impact on error disclosure. Basically, on the question of whether they’d be held personally accountable for their errors, hospital workers’ beliefs were all over the place — but had little effect on their likelihood of reporting an error. That’s not great news for the pursuit of full and transparent error reporting; changing the blame culture was touted as a big step forward, but might actually be just a lateral move. And so the search for an effective way to increase healthcare staff’s willingness to report their mistakes soldiers on.

Psychologists face a similar sort of problem. The success of talk therapy requires something like radical honesty; progress absolutely depends on the patient’s willingness to cop to difficult truths. Granted, revealing a misstep to your therapist isn’t likely to cost you a job or sully your professional reputation, but there’s still real psychic cost to admitting a failure to someone else. And, in many other ways, therapy confessions are remarkably similar to medical error reporting: in both cases, the individual is the only possible source critical information, there’s an easy way out that comes with a lot less short term hassle, and there’s at least a partial abdication of personal or professional autonomy.

Yet, psychologists don’t view the (non-)assignment of blame as a universal panacea. Instead, their aim is to construct an environment where the patient feels comfortable communicating anything and everything, regardless of who’s at fault. This requires fostering what the psychologists Harry Reis and Phillip Shaver refer to as intimacy [2]. In the Reis and Shaver model, intimacy implies trust and emotional proximity, but not romantic love or the other usual associations with intimate relationships. Instead, they describe intimacy as a component process where Party A’s self-disclosure triggers feedback from Party B, which then elicits further disclosure from Party A, and on and on.

That feedback is paramount. People who receive appropriate and personalized responses to self-disclosures report stronger feelings of connectedness to the therapeutic process than those who get generic feedback or none at all [3]. The resulting bump in intimacy presumably lays the foundation for further, deeper self-disclosures. By this reckoning, intimacy isn’t just an aspirational feeling; it’s a tool that therapists actively use to induce difficult disclosures from their patients.

Self-disclosure in the setting of medical errors seems to adhere to the roughly the same process. It might seem strange to contemplate the need for a hospital to create an environment of intimacy with its employees, but that may be precisely what’s required. Doctors and nurses are ultimately individually responsible for deciding whether or not to file error documentation, but that choice is colored in part by what their employers do with the information. Unsurprisingly, in the same study that downplayed the importance workplace blame culture, the single strongest determinant of error self-reporting was whether staff was provided with feedback to disclosures [1]. The association between high quality feedback and submitting error reports was more than twice as strong as the link between reporting and the severity of the blame culture. Just like in the therapist’s office, the hospital’s commitment to feedback — regardless of the nature of its blame culture — was the most powerful motivator encouraging people to tell the whole truth. It turns out that when it comes to reporting medical errors, hospital staff don’t need absolution. They just need to know that they’re being heard.


[1] Burlison, Jonathan D., et al. “A Multilevel Analysis of US Hospital Patient Safety Culture Relationships With Perceptions of Voluntary Event Reporting.” Journal of patient safety (2016).

[2] Reis, Harry T., and Phillip Shaver. “Intimacy as an interpersonal process.” Handbook of personal relationships24.3 (1988): 367-389.

[3] Haworth, Kevin. “The Impact of Feedback in Response to Self-Disclosure on Social Connection: a Possible Analog Component Model of the Therapy Relationship.” (2014).