Otro obstáculo para la #SegPac: la culpa – PtSafety Network

The Blame Game

One major objective of a ‘Root Cause Analysis’ is to: ‘Look for improvements rather than apportion blame’

Recently, a tragic gas pipeline crossover resulted in death of a newborn, and left another with severe brain injury.

Prior to this incident many clinicians believed pipeline errors had been relegated to history. Unfortunately pipeline crossovers occur with relentless frequency (see here) – the RCA team may not have appreciated this. This affects the focus of their report – instead of finding solutions for preventing similar adverse events in the future they look at what could have stopped it in the past – a subtle difference and consequently the RCA recommendations appear like veiled forms of blame:

Para acceder al sitio, haga Clic Aquí

2010 © Foro Latinoamericano Colaborativo en Calidad y Seguridad en Salud

Desarrollado por IECS (Instituto de Efectividad Clínica y Sanitaria)

Log in with your credentials

or    

Forgot your details?