Are your people too afraid to report errors?

AHRQ finds many employees think hospital culture is too punitive

Perhaps the saddest thing about the Hospital Survey on Patient Safety Culture: 2012 User Comparative Database Report, released in February by the Agency for Healthcare Research and Quality (AHRQ) is not that so many people believe the culture in their hospitals is an impediment to error reporting, but that so many people who work in the patient safety arena are not surprised at the high number of people responding that way.

The survey included about four dozen questions about the safety culture, including queries about overall perceptions, staffing, communications, and transitions. (For a list of some of the questions, see box, below.) For example, nearly two-thirds of respondents think it is pure luck that more errors do not happen and that there are safety issues on their unit; fewer than half those responding feel free to question those above them, even if they think they might be making a mistake, and 63% are afraid to ask questions if something seems off. Half the respondents think their mistakes are held against them, and nearly as many think the organization looks for a person to blame, rather than a problem to solve. In the last year, none of those numbers had moved in a positive way more than 2%, and most were unchanged from the previous year. (The complete report is available online at

"If something is not obviously the result of a process breakdown, people like someone to blame if something goes wrong," says Frances Montoya, manager of the patient safety program for Presbyterian Healthcare Services in Albuquerque, NM.

Barbara Rebold, RN, MHA, CPHQ, director of operations at the ECRI Institute Patient Safety Organization in Plymouth Meeting, PA, agrees. "It is human nature to find someone to blame and make an example of them, rather than looking at the system and why the system might be an issue."

Often, Rebold says, management will object to creating an organization that has an open and non-punitive culture, saying it lacks accountability. "But there is a difference between accountability and blame," she says. "It is a fine line, but there is a difference." Accountability means people feel responsible for making things happen, bringing hazards to light, and stopping activity if necessary. "People have to be empowered to be accountable. It is easier to blame a person, or educate, train, or discipline him, than to create the systems that empower them. But despite the effort, it is better in the long run to help them be willing to report errors and near misses."

"Dr. [W. Edwards] Deming said that errors are usually the responsibility of the system, not the worker," explains Cary Gutbezahl, MD, president and CEO of Compass Clinical Consulting of Cincinnati, OH. Gutbezahl consults with many organizations about creating a non-punitive culture for error reporting. "But that does not fit well with healthcare. We do not have well-designed systems, but rather we rely on good people to implement processes. We have an operator-dependent system, and that does not create teamwork, transparency, or effective error-proofing."

The number of employees who feel they work in a punitive environment? It is not surprising, he says, in context of the kind of industry healthcare is and the place on the quality path where it is at this point.

That does not mean you can't create an environment where the survey numbers seem wrong, sad, or ridiculous. Montoya says Presbyterian Healthcare Services started working on rolling out a Just Culture program in 2009. Based in part on training from the Institute for Healthcare Improvement, it started with an in-depth look at the constraints that existed around not identifying potential places of harm. "You have to know first where you are harming people," she says. "Then you can determine how to prevent that harm."

The worry that many had was that you would end up with a system that had no accountability, but Montoya says they got around that by making the message clear. "We recognize that healthcare is complex, with a lot of changes and handoffs. There will be mistakes. But we will be transparent, share where there are areas where we are prone to mistakes and figure out how to fix them. If you speak up about an error or near miss, we will use that as a learning experience. This is not a blame-free culture, but we want you to speak up. If you do, you will not be punished."

The initial inquiry into errors focused on pressure ulcers, surgical-site infections and other problems that could be identified using existing coding to capture. "We did quarterly reviews," Montoya says. "We sent them to the boards, and while at first they wanted to know who was making mistakes, over time they stopped."

Next, Montoya says they put together a Significant Clinical Review Team. "Before, it was just one person who dealt with events. The team included risk management, nursing, pharmacy, and HR." They began to notice trends — things that happened more than once, providers who had the same problem repeatedly. They created Red Rules — the things for which providers are responsible 100% of the time and if not done result in some sort of remediation, punishment, perhaps even termination.

Gutbezahl spent some of his clinical life managing a blood bank. Red Rules there included following strict procedures for releasing blood from the bank to the nurses and up to a unit. If they were not followed every single time, it led to immediate termination.

One of the first Red Rules Montoya says they implemented in Albuquerque related to hand hygiene; another related to positive patient identification using name and date of birth. While things have improved in the year since the rules were rolled out, Montoya says they still struggle with the line between accountability and blame, even with the Red Rules. Who has to see you not washing your hands? If you have a verbal reminder, is that considered breaking the rule, even if you haven't touched a patient yet? What if it is a particularly frantic day and you miss something, but then come back and correct yourself, but your manager notices? A recent outbreak of norovirus allowed them to revisit the importance of hand hygiene. "If employees had been more accountable for this, maybe it wouldn't have spread so far," Montoya says.

Still, she counts the program as a success. "We have a safety culture now, not just a culture. And it is not about what just happened, but about the next patient. It is not about your role or relative position with the person you are questioning or correcting. It might sound like a no-brainer to call each other on hand-washing, but it does not always happen. So we have to give them better tools on how to approach their peers and co-workers. And we have to have the rules and hold every person accountable the same way — doctors and nurses."

Rebold says the key to implementing a non-punitive culture is making sure that from the very top down, everyone supports the idea that you aren't looking for the person whose head needs to roll. When people talk about errors — and they talk about them whether you have a punitive culture or not — the conversation will include whether someone was scape-goated. When you stop blaming individuals and start looking at systemic reasons for errors, that word will spread. People will, over time, begin to feel more comfortable reporting mistakes. "Staff will begin to see there is no reason to keep secrets and hide reports," says Rebold. "They will understand that the risk is patient safety, not job or income security."

You also have to have good ways to determine if there was any intentional human error, Rebold notes. "And that's not as easy as you think." There are tools that come from other industries that can help. ECRI has one available through its website. Another important tool, she says, is something that evaluates the various corrective actions you can take. ECRI has one of those, too, which outlines low-, medium- and high-impact methods of effecting change. Most people stick to things such as education and remediation, which are on the low end. "You need to choose actions that have higher impact, like optimizing redundancy through second checks, minimizing choices, or standardization." Those fall into the medium category. Failsafe mechanisms like Red Rules, stopping the line or automation are high-level actions. "Do not do something on the low end alone. If you do those alone, you will not have improvement."

Gutbezahl recommends talking to employees first to get their opinion on your culture. Then create your message and disseminate it. It could be as simple as "We work as a team, and any member of the team can speak up." Ensure acceptance at the top and roll it out to management — not just senior management, but managers from every level of the organization — before expanding it to everyone. Buy-in is crucial, he says.

"Fear is the enemy of quality," he says. "If people are afraid, they cover up errors and you get under-reporting of problems." That can lead to poor mortality and readmission rates; quality improvement departments will not know what needs fixing, either at the system level or even at the individual patient level.

Expect the changes to take about a year to percolate through your organization, Gutbezahl concludes. Reassure your staff that you are committed to changing the culture and when events happen, encourage discussion. "Say you used to have surgeons come in and complain about nurses who raise questions. You do not fire the nurse though. You talk about teamwork with the doctor and the nurses and how to have constructive conversations in surgery. People will hear about that. They will know that the nurse raised a concern and nothing bad happened."

For more information about this topic, contact:

  • Frances Montoya MT(ASCP), Manager, Patient Safety Program, Presbyterian Healthcare Services, Albuquerque, NM. Telephone: (505) 724-7909.
  • Barbara Rebold, RN, MHA, CPHQ, Director of Operations, ECRI Institute Patient Safety Organization, Plymouth Meeting, PA. Telephone: (610) 585-5881.
  • Cary Gutbezahl, MD, President and CEO, Compass Clinical Consulting, Cincinnati, OH. Telephone: (513) 702-5654. Email:

Further Internet Resources:

Just Culture website:
ECRI Institute website:
California Hospital Patient Safety Organization website:
Compass Clinical Consulting resource links:

Select questions from AHRQ

Hospital Survey on Patient Safety Culture: 2012 User Comparative Database Report

Percent Responding Yes

Overall Perceptions of Patient Safety

  1. It is just by chance that more serious mistakes do not happen around here. 62%
  2. Patient safety is never sacrificed to get more work done. 64%
  3. We have patient safety problems in this unit. 64%
  4. Our procedures and systems are good at preventing errors from happening. 72%

Feedback & Communication About Error

  1. We are given feedback about changes put into place based on event reports. 56%
  2. We are informed about errors that happen in this unit. 65%
  3. In this unit, we discuss ways to prevent errors from happening again. 72%

Frequency of Events Reported

  1. When a mistake is made, but is caught and corrected before affecting the patient, how often is this reported? 57%
  2. When a mistake is made, but has no potential to harm the patient, how often is this reported? 59%
  3. When a mistake is made that could harm the patient, but does not, how often is this reported? 74%

Communication Openness

  1. Staff will freely speak up if they see something that may negatively affect patient care. 75%
  2. Staff feel free to question the decisions or actions of those with more authority. 47%
  3. Staff are afraid to ask questions when something does not seem right. 63%

Nonpunitive Response to Error

  1. Staff feel like their mistakes are held against them. 50%
  2. When an event is reported, it feels like the person is being written up, not the problem. 46%
  3. Staff worry that mistakes they make are kept in their personnel file. 35%