Most errors are the result of flawed processes and searching for individual culprits often results in missing the underlying root cause.
Blaming individuals creates a culture of fear and defensiveness leading to:
- Diminished learning
- Diminished capacity to improve systems
Reducing or eliminating harm to patients is the real key to patient safety. Efforts that focus exclusively on elimating errors will fail. We will never eliminate all individual errors. The goal is to design systems that are "fault tolerant", so that when an individual error occurs, it does not result in harm to a patient.