Sir, – The Health Information and Quality Authority has released yet another report critical of hand-hygiene practices in hospitals, and the immediate response from the hospital concerned is to introduce aggressive, disciplinary-based approaches to ensure hand-hygiene compliance (“Hygiene at Wexford hospital criticised in Hiqa report”, June 11th). With these reports becoming more common, might I suggest we adopt a different approach to hand-hygiene compliance?
In other areas of healthcare, in particular surgery, a “no-blame” culture is now standard. In the event of an error, it may be instinctive to seek immediate punishment, but this paradigm is actually counterproductive to preventing further errors. While it discourages blame, it is not a “no-fault” system. It does not tolerate malicious or purposefully harmful behaviour, and supports disciplinary actions against those who engage in such behaviour. This culture recognises that human error and faulty systems can lead to mistakes and encourages an investigation of what led to the error, instead of an immediate rush to blame an individual. Through this process, systems that may perpetuate errors can be fixed. It also gives healthcare professionals the opportunity to feel more at ease reporting errors and a sense of empowerment for system improvement, instead of being afraid. – Yours, etc,
Dr PETER LONERGAN,
Dargan Building,
St John’s Road West,
Dublin 8.