RCN blog - Blame, shame and retrain? There’s a better way to learn (4 July 2022)

Summary

In this blog, nurse Carol Menashy describes her experience making an error in theatre fifteen years ago, and the personal blame she faced in the way the incident was dealt with at the time. She talks about how a SEIPS (Systems Engineering Initiative for Patient Safety) framework can transform how adverse incidents are dealt with, allowing healthcare teams to learn together and use incidents to help make positive changes towards patient safety. She describes the progress that has been made towards organisational accountability and systems thinking over the past fifteen years, and talks about the importance of staff support to allow for healing from adverse events.