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Second Victim, accountability and no blame culture... can these three exist together?

Claire Cox

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Following the posting of the recent anonymous blog by a brave nurse  - a discussion was started on Twitter about the aspect of accountability, duty of candour mixed with a no blame culture.

If there has been a drug error:

  • The person who did the error needs to feel secure in the knowledge that there is a no blame culture, otherwise they may not report it in the first place. 
  • The patient needs to be told that they has been an error with their care
  • The person who did the error needs to be held to account

So, can these three points coexist or are we wanting the impossible?


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I think it’s difficult sometimes to get the balance right, I don’t think it’s a ‘see saw’ I think it’s a balance act of ‘multi-elements’ 

One one hand the patient who should be our main priority and making sure that Candour and communication of the incident happens. 

Another side of this would be the investigation itself, which I think people tend to follow the pathway to the letter, however in these pathways, there is no documentation about ‘support for individual’ I have done training linking with this in the past, but there was never a mention of supporting individual, only focusing on the process etc. 

Then you have your individual who has completed the error, and whether they are suspended/ continuing to work, they are going through an awful time with over analysing the situation, and feeling pressure on the shoulders. 

So I think it’s much more complex than what many may perceive.... I am sure I’m not the only one to say I have made an error, and I am proud of the nurse who posted the original post! Thank you 

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It is I agree, a multi faceted set of issues. Really appreciate the honesty and bravery of people who share their experience and perspectives. 

As a patient I want to ensure that any error and harm is recognised and that I or my family are supported in whatever way I need. I want to know that the organisation providing me with care understands what went wrong and has an appropriate response, whether there are systemic issues that need to be addressed or whether there are support or performance management issues with staff involved. I want such processes to be fair, that there is learning and this is acted upon and that the risk of error and harm is reduced. I want there to be learning from the overall process of investigation, for there to be support (to patients and staff) and that learning is shared for wider improvement.  I want staff not to fear making an error (healthcare is complex and we work in systems that often aren't designed or operate effectively for safety) and if they do, they should not be victimised. Any suggestion of deliberate harm or wilful negligence is different and this should be addressed fairly and swiftly. The health care system needs to be accountable for its performance and the safety of the care it provides - this, in my view, is an organisational leadership responsibility that shouldn't be dumped onto individual staff members. 

We have been engaging with a colleague from a Trust in London about the support they are developing for staff; what has often termed the 'second victim.' Maybe this is now an unfortunate phrase as we better understand what harm is done to families and friends when there is unsafe care. So language aside, we need to support staff to share their experiences and support them to deal with the processes that they will go through and the guilt and self blame they often experience. It is welcome to hear that there are fabulous resources being developed and we are keen to write them up for wider sharing. 

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Hi Carol @Carol Menashy

I’ve seen your article on the hub and am really interested in how you’ve implemented this in your Trust . It’s something that we are looking at doing here. Do you have any guidance, processes etc that you follow that you would be able to share?

Any information would be really useful, thank you.


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1. Yes there should be a 'just and learning' (rather than 'no blame') culture which encourages reporting and reduces the risk of people feeling tempted to cover up, but....

2. The existence of an unsatisfactory culture does not excuse departure from required professional and statutory duties such as the duty of candour. The patient has to be told in accordance with these. It's simply an essential part of being a health professional, but...

3. Being 'held to account' does not mean the person who made an error should be punished. It is about having insight, committing to learn from the incident, and doing the right thing by the patient. If on the other hand the duty of candour is not complied with, then the person / people responsible should definitely be held to account in a more formal disciplinary/regulatory way

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Thanks @Peter Walsh. And that accountability is also organisational. A just and learning culture means that organisations learn from unsafe care and good practice, taking action to reduce the risk of future harm. And to share that learning, widely.

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