The diagnosis and treatment of blame

Blame typically follows an adverse event, blame of self and blame of others. However, blame confounds efforts to identify and fix fatal systems flaws. Outlined here are four practical techniques for overcoming blame and identifying systems. Most importantly, blame must be expected and recognized in its many aspects; once recognized, it can be overcome. Other' approaches include isolating decisions about discipline from the systems review process, distinguishing between an adverse clinical outcome and a systems flaw, and asking the right questions atthe beginning of analysis.