Much of the patient safety literature calls for improved incident reporting systems that include
less focus on finding fault and greater attention to the context in which the error
occurred.2, 3, 63, 64, 65 Adding OBM to this directive could have an immediate positive impact.
Winokur and Beauregard38 offer a checklist for ensuring that investigations of caregiver errors
are performed with a process focus, placing emphasis on specific task demands and contextual
factors, rather than on the identification of individuals at fault. Anonymous error reporting and
group feedback can influence individual behavior without assigning personal blame for poor
performance.