SafetyInsights.org

Here’s another compendium of articles exploring blame and language in the construction of post-hoc causality explanations, or how blame effects learning and investigations.

The other part covers some articles around Just Culture and restorative culture.

Note: I’ve mostly focused on articles that I’ve either already summarised or that I could find a full text link for. It’s not systematic.

If you’d like to support my site then feel free to shout a coffee:

BLAME & LANGUAGE

Blame, guilt and punishment and the language of investigations

Blame Conformity: Leading Eyewitness Statements can Influence Attributions of Blame for an Accident

How does leading eyewitness statements influence attributions of blame in investigations? Does blame shift between people?

A Review of Literature: Individual Blame vs. Organizational Function Logics in Accident Analysis

The folly and blame of objectivist and rationalistic investigations – the Waterfall train accident

Attributions of blame and individual error in workplace assault and aggression mask the underlying issues

Blame climate found to enhance error learning (* with caveats)

Professional accident investigators attribute more blame to workers than laypeople, exhibiting a “human error bias”

The unintended consequences of no blame ideology for incident investigation in the US construction industry

The blame cycle

Nature of Blame in Patient Safety Incident Reports: Mixed methods analysis of a national database

Pointing Fingers: Verbosity of Patient Safety Narratives Is Associated With Attribution of Blame

Subtle linguistic cues influence perceived blame and financial liability

Factors affecting learning from incidents: A cross-industry review

“Those found responsible have been sacked”: some observations on the usefulness of error

Coronial inquiry: Not hard to find human ‘culprits’ and “we must beware of falling prey to the fundamental attribution error (i.e. blaming people and ignoring situational factors)”

Modifying an accident process and its justice system – From single narratives and retribution to multiple stories and restoration

How not to investigate an accident

From punitive action to confidential reporting: A longitudinal study of organizational learning

Replacing Hindsight With Insight: Toward Better Understanding of Diagnostic Failures

Experts under the microscope: the Wivenhoe Dam case

Using stories to battle unintentional injuries: Narratives in safety and health communication

Boards of directors’ influences on occupational health and safety: a scoping review of evidence and best practices

Attributions of accidents to “human error” in news stories: Effects on perceived culpability, perceived preventability, and perceived need for punishment

Human error or an error trap ready to strike? The case of a mechanical press arm amputation

Biases in construction safety investigations – roleplay scenario study

The context and habits of accident investigation practices: A study of 108 Swedish investigators

Biases in incident reporting databases: an empirical study in the chemical process industry

Accident Report Interpretation

Learning from Mistakes Is Easier Said Than Done: Group and Organizational Influences on the Detection and Correction of Human Error

Moving on after critical incidents in health care – A qualitative study of the perspectives and experiences of second victims

Overlooking causes in healthcare accident investigation: Choosing the analysis is choosing the results

Reflections: Voice and Silence in Workplace Conversations

Heuristics and biases in judicial sentencing

https://doi.org/10.1177/1541931218621370

https://doi.org/10.1016/j.ssci.2020.104968

https://doi.org/10.1080/00140139.2020.1744064

https://pmc.ncbi.nlm.nih.gov/articles/PMC3115647/

Click to access OGGHBK_2016_v35n3_143.pdf

https://www.mdpi.com/1660-4601/16/23/4826/pdf

Click to access Beyond-blame-A-systemic-accident-analysis-through-a-neutralized-human-factors-taxonomy.pdf

https://doi.org/10.1016/j.aap.2015.01.016

Click to access A-new-perspective-on-blame-culture-An-experimental-study.pdf

Click to access Overcoming-the-blame-game-to-learn-from-major-accidents-A-systemic-analysis-of-an-Anhydrous-Ammonia-leakage-accident.pdf

https://www.sciencedirect.com/science/article/pii/S0001691823002007

Click to access Burger-PB-1981.pdf

https://journals.plos.org/plosone/article/file?id=10.1371/journal.pone.0128329&type=printable

JUST CULTURE / RESTORATIVE CULTURE

From individual behaviour to system weaknesses: The re-design of the Just Culture process in an international energy company. A case study

The process and perspective of serious incident investigations in adult community mental health services: integrative review and synthesis

Reporting of health information technology system-related patient safety incidents: The effects of organizational justice

A culture of openness is associated with lower mortality rates among 137 English National Health Service Acute Trusts

Restorative Just Culture Checklist

The Barriers and Enhancers to Trust in a Just Culture in Hospital Settings: A Systematic Review

Just culture’s ‘‘line in the sand” is a shifting one; an empirical investigation of culpability determination

Restorative just culture significantly improves stakeholder inclusion, second victim experiences and quality of recommendations in incident responses

Restorative just culture significantly improves stakeholder inclusion, second victim experiences and quality of recommendations in incident responses

Link: https://safety177496371.wordpress.com/2023/08/21/restorative-just-culture-a-study-of-the-practical-and-economic-effects-of-implementing-restorative-justice-in-an-nhs-trust/

https://doi.org/10.3390/healthcare12202046

https://doi.org/10.1016/j.ssci.2016.01.018

https://www.mdpi.com/2227-9032/9/10/1324/pdf

https://journals.sagepub.com/doi/pdf/10.1177/0004867420918659

https://doi.org/10.1016/j.apnr.2020.151319

Click to access SjaeWrbjSmenkl4Nok8Z_JustCultureCTW.pdf

https://www.tandfonline.com/doi/pdf/10.1080/14773996.2017.1341596

Click to access e061321.full.pdf

Click to access s12913-022-08418-z.pdf

Link: https://www.academia.edu/download/113547601/viewcontent.pdf

https://doi.org/10.1016/j.ssci.2023.106074

Click to access DOPHTU_From_Restorative_Justice_to_Restorative_Culture.pdf

https://www.mdpi.com/2227-9032/9/10/1324/pdf

https://www.sciencedirect.com/science/article/abs/pii/S0897189718305950

Click to access Conference%20Paper_CIB_W099%26W123_Cultivating%20just%20culture%20in%20construction.pdf

Link: https://doi.org/10.1016/j.ssci.2017.01.008

Click to access s12913-022-08418-z.pdf

Click to access pdf

LinkedIn post: https://www.linkedin.com/pulse/blame-just-culture-language-ben-hutchinson-6ffqc