How can you safely report incidents without assigning blame?

We grow up with it: we like to point out the things others do wrong. This starts from an early age. Who did not have to stand in the corner as a child, at home or at school, because you had done something that was not allowed? Exactly, everyone, and we often continue this behaviour later in life.

Punishing people for doing something wrong creates a culture where people do not dare to report incidents (or potential for improvement). This is the opposite of what you want to achieve, namely: reporting incidents so you can ensure a safe(er) working environment.

But how do you do it? By creating psychological safety, an atmosphere in which it is safe to report incidents. In other words: from finger-pointing in a blame culture to safety in a Just Culture, also known as Safe Incident Reporting.

Blame-culture

To blame, is something you should not want. Yet it still happens all too often. When an (almost) incident occurs, we almost automatically start looking for the guilty party. Who made a mistake? Who provided the wrong information?

These kinds of questions naturally lead to a person (or persons). In almost all cases, people do not consciously make the mistake. If they are at all aware that they made a mistake, it does not mean that they did so intentionally.

So placing blame is counterproductive. Because if there is punishment for a mistake you made (unknowingly), why would you admit you made a mistake? Indeed, it’s better not to.

Why punishment never really helps

Punishment. Whether it’s punishment after an incident, or when someone doesn’t do what you want them to do, it never actually works. At least, it doesn’t work in the long run. Initially, the shock is there after a punishment, but this feeling, and thus the desired behaviour, disappears fairly quickly.

What remains is the fear of doing it wrong (again), which doesn’t help the atmosphere and trust. You also create a culture where mistakes are hidden and swept under the carpet, critical and creative thinking dies out and there is no room to learn from mistakes.

As a result, many employees will eventually leave the organisation as this is not a pleasant way of working for anyone.

If someone makes a mistake, you can assume it is due to misinformation or other external factors that make the displayed behaviour the norm for that person at that moment. So if work instructions are not easy to find and consult, if protective equipment is not readily available, or if there is more pressure to do something quickly than safely, can you really blame people when things go wrong?

Let’s argue together that not. Away with the blame culture, it really is out of date!

Just Culture

Just Culture is the opposite of blame culture. It stands for psychological safety, or the culture in which incidents can be safely reported without having to answer the question of blame.

It should also ensure that people can openly and honestly answer questions about the incident and their possible role in it, without being punished for it. In the Netherlands, we know this, especially in healthcare, by the term Safe Incident Reporting.

So Just Culture is about safely reporting and analysing incidents without pointing fingers or (personally) accusing people. This does demand something from safety experts and managers: they have to know how to create psychological safety.

This goes beyond simply removing the blame, people really need to feel comfortable to open up. So the whole atmosphere in a work environment must be pleasant, a form of mutual trust and maybe even companionship must develop.

That is why it is important to take part in team outings or company activities. But even having lunch together and other small things can ensure that a bond is created, creating a pleasant environment where people are inclined to share their experiences, both positive and negative.

Safety II

There is also a positive trend in healthcare, which is called Safety II. This encourages incident analyses not only to look at what didn’t go well, but also to highlight the points that did go well.

This is not the same as Just Culture, which is about removing blame. However, by naming the positive things, it can contribute to the atmosphere in which reporting incidents can be done safely.

In other words, if the positive things are also seen, a psychological safety can be created where people more readily admit what didn’t go right.

Safe Incident Reporting

These new insights thus focus on safe incident reporting. Just Culture is therefore known as Safe Incident Reporting. For this purpose, many organisations, especially in healthcare, have established a procedure.

This is a positive trend, while many organisations outside healthcare still have a battle to fight in this area.

But besides psychological safety, it is also important to be able to report incidents (literally) safely in other areas.

For instance, it is easy to be able to do this on the spot. So instead of waiting until you are behind a computer or able to get hold of a form, you can do it with your smartphone. This makes the report more reliable, which makes your incident analysis all the more powerful and allows improvement measures to be taken.

This, if all goes well, leads to a safer situation in the future.