Learning from Adverse Events:

Apology, Forgiveness & “Just Culture”

Murray Anderson-Wallace

3 Propositions

• We need to rethink the relationship between error and blame

• We urgently need to improve the quality of response after harm

• We need to actively challenge the cultures of “passive” denial that threaten improvement

“To Err is Human” Institute of Medicine (1999)

“An Organisation with a Memory” Sir Liam Donaldson (2000)

Reviews in NHS Ayrshire & Arran (2012)/ NHS Lanarkshire (2013)

Francis Inquiries (2010, 2013)

Keogh Reviews (2013-14)

“A Promise to Learn, A Commitment to Act” Berwick et al (2013)

Proposition 1

We need to fundamentally rethink the relationship between error and blame…

Proposition 1

We need to build a relationship between error and forgiveness…

“Forgiveness is a worthy response to the admission of true human error”

Berlinger 2003

To forgive is divine…

(Pope 1711)

“Forgiveness is ‘giving up all hope of a better past.’

It is an act of self-healing, rather than an act of kindness towards someone who has hurt you”

The Forgiveness Project

“Forgiveness liberates the soul, it reduces fear. That is why it is such a powerful weapon ”

Nelson Mendela

“If learning is the starting point then forgiveness may be the turning point”

Anderson-Wallace 2014

Don’t confuse forgiveness with “cheap grace”

Cheap grace is the systematic expectations of forgiveness and is often associated with a lack of convincing account of what went wrong or

and acknowledgement of the reality of their suffering

Bonheoffer (1938) Berlinger (2003)

Some stories to bear in mind…

Craig McDonald Paul Richards Bethany Bowen

Making distinctions…

• Honest mistake?

• Willful violation?

• Reckless decision?

• Gross negligence?

Just Culture…

• Creating a balance and between accountability & learning

• Clarity about HOW & BY WHOM the line is drawn but it is not necessarily easy to determine exact WHERE it is to be drawn?

• Consistency between “story lived and the story told” Source: Sidney Dekker

How is it done?1. Avoid the trap of the illusion that their are clear or absolute lines

between acceptable and not acceptable

2. Carefully assess the way you deal with incidents

3. Ensure that your approach to reporting & investigation is properly independent

4. Protect your data from undue probing (determining who is involved in drawing the line)

5. Be very clear about how the internal process works (minimises anxiety about line-drawing) and make sure it is consistently applied

Source: Sidney Dekker

A shift to finding out “what” went

wrong rather than just asking “who”

went wrong?

“Enhancing clinical performance through an understanding of the effects of teamwork, tasks, equipment, workspace, culture, organisation on human

behaviour and abilities, and application of that knowledge in clinical settings.”

Catchpole 2009

Clinical Human Factors

Proposition 2

We need to urgently improve the quality of response after harm has occurred…

Bethany Bowen

Improving the quality of response

(Anderson-Wallace & Shale 2014)

Publications

Proposition 3

We need to understand and then actively challenge the culture of “passive” denial

The unique challenges of preventable error in healthcare

• Healthcare is a very “risky business”

• Healthcare has an unusual “moral order”

BOTH makes notions of “wrong doing” much harder to determine

A defence against anxiety?

“In healthcare organisations, calm confidence is prized and the system has honed its ability to achieve it. Emerging issues, which exacerbate anxiety -

like safety concerns, near misses and actual errors - are therefore often not welcome.

In this context there is a risk that people are too keen to be easily reassured and therefore close down difficult conversations and questions too early.

This frustrates those who have concerns and speak up, while others become accustomed to deficiencies and dangerously accepting and passive”

Dame Elizabeth BugginsEvidence to the Francis Inquiry 2011

How is this sort of culture changed?

Challenge the overly rational, unemotional discourses and mechanical modes of operation

Pay much greater more attention to the “meaning” of adverse events

Reconnect with our sense of fundamental humanity & our innate empathic abilities

Always ask what you would want for yourself or a member of your family

“If there is one lesson to be learnt, I suggest it is that people must always come before numbers. It is the individual experiences that lie behind statistics and benchmarks and action plans that really matter, and that is what must never be forgotten when policies

are being made and implemented.’

Robert Francis QC 2010

JusticeFairness

TransparencyPrudenceWisdomAltruism

CompassionCivility

“Systems awareness and systems design are important for health professionals, but they are not

enough. They are enabling mechanisms only.

It is the ethical dimensions of individuals that are essential to a systems success. Ultimately, the

secret of quality is love” Avedis

Donebedian(1919-2000)

Thank you for your attention