> >Jack, “blame-free accident investigation” is not at its core a “more compassionate approach.” It is a process, originally developed in fields like aviation, to improve the chances of an incident or near-miss being reported in the first place, and then of the investigation receiving truthful reports/descriptions from those involved because they are confident those investigators will not seek to blame or punish them, but merely determine the sequence of what happened and why. In many cases a separate assessment of blame may follow, but that is done by an entirely different set of people seeking to determine whether required procedures were, or were not, followed.
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Unfortunately, the distinction that Peter is pointing to is more subtle than the legal system accepts in some instances. One specific example of this is the experience of RaDonda Vaught, a former nurse. Details can be found at
https://en.wikipedia.org/wiki/RaDonda_Vaught_homicide_case

A summary of the Wikipedia article is:

The RaDonda Vaught homicide case was a 2022 American legal trial in which a former Vanderbilt University Medical Center the former nurse was convicted of criminally negligent homicide and impaired adult abuse after she administered the wrong medication that killed a patient in 2017. She was sentenced to three years' probation. RaDonda self-reported the error. She had overridden the defaults of the electronic dispensing system to get the medication, which turned out to be incorrect for this patient. This override approach was used by nurses throughout the hospital.

The American Nurses Association stated:
"We are deeply distressed by this verdict and the harmful ramifications of criminalizing the honest reporting of mistakes.

"Health care delivery is highly complex. It is inevitable that mistakes will happen, and systems will fail. It is completely unrealistic to think otherwise. The criminalization of medical errors is unnerving, and this verdict sets into motion a dangerous precedent. There are more effective and just mechanisms to examine errors, establish system improvements and take corrective action. The non-intentional acts of Individual nurses like RaDonda Vaught should not be criminalized to ensure patient safety.

"The nursing profession is already extremely short-staffed, strained and facing immense pressure – an unfortunate multi-year trend that was further exacerbated by the effects of the pandemic. This ruling will have a long-lasting negative impact on the profession.”

The American Bar Association issued a statement saying that, "A robust culture of safety relies on self-reporting and transparency to drive process improvement, and criminalizing errors instead foments blame and creates fear."

More information available on this situation is available in the Pre-Accident Podcast Episode 385 - A Nurse Manager on Blame and Punishment
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My take away from this is that if compassion is not part of the profession’s culture, as expressed in the incident investigation process, high stress professions will have increased employee retention problems. Given the drop out rate of STEM majors from chemistry classes, I suspect that lab chemistry is in a profession in that category.

- Ralph

Ralph Stuart, CIH, CCHO
ralph**At_Symbol_Here**rstuartcih.org

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