TL;DR:
Blaming workers after mistakes makes organizations less safe. Psychological safety shifts the focus from “who failed” to “what in the system allowed this to happen,” leading to better learning, prevention, and patient safety.
Why Blaming Workers Fails to Improve Safety
I recently wrote a post for the Value Capture blog that you might be interested in:
Psychological Safety Means It's Safe to Ask for Help When You're Unsure
What Psychological Safety Means in Practice
As I wrote in the post… Our definition of a phrase that's very important to us starts with:
Psychological safety is “the belief that the environment is safe for interpersonal risk-taking by any person.”
We need to shift from a culture of “naming, blaming, and shaming” toward one that has psychological safety for our staff and providers. This psychological safety leads to better physical safety for staff and patients.
A Real-World Example: When Culture Contributes to Harm
In the post, I tell a story about an incident that caused minor harm to a clinic provider… and why the culture (including a lack of psychological safety) might really be to blame.
I hope you'll check it out. Feel free to comment here or on social media if you have thoughts to share.
The Full Post:
Our definition of a phrase that's very important to us starts with:
Psychological safety is “the belief that the environment is safe for interpersonal risk-taking by any person.”
“Risk taking” has to be carefully defined. We don't mean that risk-taking (or being reckless) is OK when the health and safety of oneself, colleagues, and patients might be affected.
We're talking about “interpersonal risk-taking,” which means the risk of speaking up to others. It can be risky, in some workplaces, to speak up to:
- Point out a problem
- Discuss an opportunity for improvement
- Disagree with your manager
- Challenge the way it's always been done.
A psychologically safe environment means we can speak up in those, and other circumstances, “without fear of being embarrassed, shamed, blamed, marginalized or punished in some way.”
This includes feeling safe speaking up with questions or asking for help. Let me share a story from some time ago.
A Story From a Clinic
At a client organization I worked with, a clinic employee was injured — being burned slightly — by sitting on a toilet seat that had some residual chemical liquid on it.
What happened?
A psychologically safe environment (which we could also describe as a “Lean culture”) focuses on what happened and why rather than focusing on the who.
Going to the workplace and respectfully talking with the people involved uncovered the following (note that leaders did not guess and hypothesize about this in a conference room).
Why did the team member suffer a chemical burn?
There was chemical on the toilet seat.
Why was there chemical present on the seat?
A clinic assistant had improperly disposed of a chemical down the toilet. Some splashed on the seat. The assistant either didn't notice this, didn't know the chemical was caustic, or both (it was both).
I think a psychologically safe workplace would not punish someone for what they didn't know, since it's management's obligation and responsibility to provide proper training and education on the work to be done.
However, some in the clinic wanted to blame and punish the employee for causing the injury.
As an advisor, I worked with leaders who were already predisposed to look at systemic root causes of a problem like this. Thankfully, they pushed back on the desire for punishment or retribution.
So What Happened?
The leaders investigated further and continued to ask ‘why?' many times, probing to find the true root cause.
Why was there chemical on the seat? The assistant dumped it in the toilet.
Why was there chemical that needed to be dumped out?
A flash sterilizer (a piece of equipment) had failed, and it did not consume all of the chemical as it should have. It commonly consumed all the liquid, so the assistant would typically throw out an empty chemical bag. There was normally no risk created by the empty container.
The clinic assistant was faced with an unusual situation. She wondered if she should dispose of the non-empty container in the usual way. She also considered pouring it into the toilet.
What Was the Real Problem and Cause?
The clinic leadership realized that a real root cause of the problem (the burn and harm) was:
Not having a culture of psychological safety where it was safe for the assistant to stop and say to a manager, “I don't know what to do with this leftover chemical. Please help me.”
This was a systemic problem, especially given the likelihood that other clinic assistants might have made the same decision if they were in that situation.
Instead of blaming the employee for not speaking up and asking for help, leaders realized they still had more work to do in order to encourage employees to speak up. This would include encouraging people to stop and ask questions if they were ever in doubt, building trust that they would not be belittled for speaking up to ask, instead of guessing and doing their best.
The Importance of Leadership
Psychological safety doesn't get established overnight. Leaders have to set expectations. They also have to set an example so their actions back up their words.
Leaders not only have to set expectations but also consistently ensure they are communicated throughout the workforce. Moreover, leaders must model the behaviors that fulfill expectations and go to the “gemba” (the actual workplace) to observe that these behaviors, through the frontline, align with psychological safety ideals.
Psychological Safety Is a Leadership Choice
Blaming individuals after something goes wrong might feel decisive, but it rarely leads to safer systems or better outcomes. When people expect punishment for speaking up, asking for help, or admitting uncertainty, the organization loses the very information it needs to improve.
Psychological safety shifts the focus from who failed to what made failure more likely. That shift doesn't lower standards. It raises them — by making it possible to see problems sooner, learn faster, and prevent harm rather than hide it.
Leaders shape psychological safety through everyday responses, not slogans or training alone. How you react when someone reports a mistake, raises a concern, or challenges an assumption sends a clear signal: speak up next time — or stay quiet. Over time, those signals determine whether improvement is real or performative.
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If you’re working to build a culture where people feel safe to speak up, solve problems, and improve every day, I’d be glad to help. Let’s talk about how to strengthen Psychological Safety and Continuous Improvement in your organization.
