With every mistake, we must surely be learning (George Harrison in While my guitar gently weeps)
Despite all the efforts deployed to reach a higher level of safety, accidents may occur in any production or service system.
An accident is a deviation from a normal process, and safety professionals investigate and analyse these events to find the complex ensemble of facts (conditions and circumstances) that contributed in the accident and elaborate actions that can be taken to make sure these conditions are mitigated against, thus preventing similar accidents from repeating.
To define a clear picture of the conditions at the time of accident necessitate the contribution of all actors. This is why a no-fault approach is a must.
Accidents occur in health care systems despite all the preventive measures.
Disclosure is only step one of the accountability and may reduce/repair the consequences for the patients and relatives. But investigation and analysis will reveal actions that can be taken to reach a higher level of safety in a pro-active manner.
All actors (patients, health professionals, managers, etc) must join together with open minds in a blame-free analysis process to work out the risks and raise the level of patient safety to a higher stage.
With every mistake, we must surely be learning!
Pierre C. Dessureault, ISQua's 2019 Patient Inclusion Scholarship Recipient, Canada