These slides were used to support Murray Anderson-Wallace's presentation at the launch of the NHS Scotland National Framework for Learning from Adverse Incidents.

1. Learning from Adverse Events:
Apology, Forgiveness
& “Just Culture”
Murray Anderson-Wallace

3. 3 Propositions
• We need to rethink the relationship between
error and blame
• We urgently need to improve the quality of
response after harm
• We need to actively challenge the cultures of
“passive” denial that threaten improvement

6. “To Err is Human”
Institute of Medicine
(1999)
“An Organisation with
a Memory”
Sir Liam Donaldson
(2000)

7. Reviews in NHS Ayrshire
& Arran (2012)/ NHS
Lanarkshire (2013)
Francis Inquiries (2010,
2013)
Keogh Reviews (2013-14)
“A Promise to Learn, A
Commitment to Act”
Berwick et al (2013)

8. Proposition 1
We need to fundamentally rethink
the relationship between error
and blame…

9. Proposition 1
We need to build a relationship
between error and forgiveness…

10. “Forgiveness is a worthy response to
the admission of true human error”
Berlinger 2003

11. To forgive is divine…
(Pope 1711)

13. “Forgiveness is ‘giving up all hope of a
better past.’
It is an act of self-healing, rather than an
act of kindness towards someone who
has hurt you”
The Forgiveness Project

14. “Forgiveness
liberates the soul, it
reduces fear. That is
why it is such a
powerful weapon ”
Nelson Mendela

15. “If learning is the starting point then
forgiveness may be the turning
point”
Anderson-Wallace 2014

16. Don’t confuse forgiveness with
“cheap grace”
Cheap grace is the systematic expectations of forgiveness and is
often associated with a lack of convincing account of what went
wrong or and acknowledgement of the reality of their suffering
Bonheoffer (1938) Berlinger (2003)

17. Some stories to bear in mind…
Craig McDonald Paul Richards Bethany Bowen

18. Making distinctions…
• Honest mistake?
• Willful violation?
• Reckless decision?
• Gross negligence?

19. Just Culture…
• Creating a balance and between
accountability & learning
• Clarity about HOW & BY WHOM the line is
drawn but it is not necessarily easy to
determine exact WHERE it is to be drawn?
• Consistency between “story lived and the
story told”
Source: Sidney Dekker

20. How is it done?
1. Avoid the trap of the illusion that their are clear or absolute lines
between acceptable and not acceptable
2. Carefully assess the way you deal with incidents
1. Ensure that your approach to reporting & investigation is properly
independent
2. Protect your data from undue probing (determining who is
involved in drawing the line)
3. Be very clear about how the internal process works (minimises
anxiety about line-drawing) and make sure it is consistently
applied
Source: Sidney Dekker

21. A shift to finding
out “what” went
wrong rather than
just asking “who”
went wrong?

22. “Enhancing clinical performance
through an understanding of the
effects of teamwork, tasks,
equipment, workspace, culture,
organisation on human behaviour
and abilities, and application of that
knowledge in clinical settings.”
Catchpole 2009
Clinical Human Factors

23. Proposition 2
We need to urgently improve the
quality of response after harm has
occurred…

24. Bethany Bowen

25. Improving the quality of response
(Anderson-Wallace & Shale 2014)

26. Publications

27. Proposition 3
We need to understand and then
actively challenge the culture of
“passive” denial

29. The unique challenges of preventable error in
healthcare
• Healthcare is a very
“risky business”
• Healthcare has an
unusual “moral order”
BOTH makes notions of
“wrong doing” much
harder to determine

30. A defence against anxiety?
“In healthcare organisations, calm confidence is prized and the system
has honed its ability to achieve it. Emerging issues, which exacerbate
anxiety - like safety concerns, near misses and actual errors - are
therefore often not welcome.
In this context there is a risk that people are too keen to be easily
reassured and therefore close down difficult conversations and
questions too early. This frustrates those who have concerns and speak
up, while others become accustomed to deficiencies and dangerously
accepting and passive”
Dame Elizabeth Buggins
Evidence to the Francis Inquiry 2011

31. How is this sort of culture changed?
Challenge the overly rational, unemotional discourses
and mechanical modes of operation
Pay much greater more attention to the “meaning” of
adverse events
Reconnect with our sense of fundamental humanity &
our innate empathic abilities
Always ask what you would want for yourself or a
member of your family

32. “If there is one lesson to be learnt, I suggest it
is that people must always come before
numbers. It is the individual experiences that
lie behind statistics and benchmarks and
action plans that really matter, and that is
what must never be forgotten when policies
are being made and implemented.’
Robert Francis QC
2010

33. Justice
Fairness
Transparency
Prudence
Wisdom
Altruism
Compassion
Civility

34. “Systems awareness and systems
design are important for health
professionals, but they are not
enough. They are enabling
mechanisms only.
It is the ethical dimensions of
individuals that are essential to a
systems success. Ultimately, the
secret of quality is love”
Avedis
Donebedian
(1919-2000)

35. Thank you for your attention