Just Culture

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Just Culture. Establishing a safety learning environment Mary Coffey. Just Culture. Encouraging reporting of Incidents and near incidents Unsafe practices To enable learning To establish a safety environment. Just Culture. Human error is a fact of life C annot be eliminated - PowerPoint PPT Presentation

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1Just Culture

Establishing a safety learning environment

Mary CoffeyROSIS - Working Towards Safer Healthcare DeliveryDublin, 11th - 14th May 2009Joanne Cunningham1Just CultureEncouraging reporting ofIncidents and near incidentsUnsafe practices To enable learning To establish a safety environment

AustraliaOctober 2012Joanne Cunningham2Just CultureHuman error is a fact of lifeCannot be eliminatedFrequency can be reduced

How are human errors managed?

AustraliaOctober 2012Joanne Cunningham3Just CultureHuman error is a fact of lifeBlameNo blameJust culture

AustraliaOctober 2012Joanne Cunningham4Blame CultureIt has to be someones faultDisciplinary approachAn easy optionSometimes appropriate

AustraliaOctober 2012Joanne Cunningham5Blame CultureFrequently not the fault of the individualDiscourages reportingFailure to learnLikelihood of repeat incidents

AustraliaOctober 2012Joanne Cunningham6No blame CultureNot the individual but the system Individuals reporting are not subject to sanction/disciplinary actionCan introduce complacencyNot always appropriate

AustraliaOctober 2012Joanne Cunningham7Just CultureAn atmosphere of trust in which people are encouraged, even rewarded, for providing essential safety-related information but in which they are also clear about where the line must be drawn between acceptable and unacceptable behavior.

Prof. James ReasonAustraliaOctober 2012Joanne Cunningham8Just CultureHuman error is a fact of lifeCompetent professionals make mistakesDevelop shortcuts (routine violations)

AustraliaOctober 2012Joanne Cunningham9Just CultureHuman error is a fact of lifeDeveloping a learning rather than a blaming cultureLearning from unsafe actsResponding

AustraliaOctober 2012Joanne Cunningham10Just CultureTrust is central to the development of a just cultureWe need to learn from our mistakesTo understand the underlying causes and address them

AustraliaOctober 2012Joanne Cunningham11Just CultureNot always blame freeA balance between the benefits of learning from incidents and the need for personal accountabilityRepeated or careless behaviourTransparent disciplinary policy

AustraliaOctober 2012Joanne Cunningham12Just CultureWell established in Aviation, Nuclear Industry and some areas of health care

AustraliaOctober 2012Joanne Cunningham13Just CultureThe Danish Naviair experienceThe introduction of non-punitive reporting for aviation professionals in 2001Number of reports in Danish air traffic control in the first year rose from approx. 15 per year to over 900AustraliaOctober 2012Joanne Cunningham14Just CultureThe Danish Naviair experiencePreviously unreported eventsIdentification of risks and trendsOpportunities to address latent safety problemsPotential major improvement in safety

GAIN working groupAustraliaOctober 2012Joanne Cunningham15Just CultureMedical Event Reporting System for Transfusion Medicine (MERS-TM)A standardised means of organised data collection and analysis of transfusion errors, adverse events and near misses.AustraliaOctober 2012Joanne Cunningham16Just CultureMedical Event Reporting System for Transfusion Medicine (MERS-TM)Effectiveness depends on the willingness of individuals to report such information

David MarxAustraliaOctober 2012Joanne Cunningham17Just CultureNot about reporting but learning from the reportingAustraliaOctober 2012Joanne Cunningham18Just Culture Why?one million people injured by errors in treatment at hospitals each year in the US, with 120,000 people dying from those injuries

AustraliaOctober 2012Joanne Cunningham19Just Culture Why?Organisational Culture in a helath care setting impacts the performance of the both organisation and the staff20Just Culture Why?the single greatest impediment to error prevention is . that we punish people for making mistakes

Dr. Lucian Leape briefing a US Congressional subcommittee

AustraliaOctober 2012Joanne Cunningham21Just Culture Why?Health care workers reluctant to reportDisciplinary based work environmentFailure on their part Loyalty to colleagues

AustraliaOctober 2012Joanne Cunningham22Just culture - Why?Modern radiotherapy is a very complex processTechnologically advanced and evolving at a rapid pace23Just culture - Why?Modern radiotherapy is a very complex processRequires the accurate application of high technology planning and treatment in an holistic environmentA six week course of radiotherapy requires over 1000 parameters to be specified (ICRP 86)24Just Culture - Why?Modern radiotherapy is a very complex processEncompasses technical, clinical, and psychosocial management of individual patientsRequires collaborative teamworkIt is expensive but subject to national and local budgetary constraints25Just Culture - Why?Modern radiotherapy is a very complex processThere are multiple processes, complex calculations and many systems where failures can occurStrongly dependent or influenced by human factorsHigh risk and error prone26Just Culture - Why?Modern radiotherapy is a very complex processFrom experience in centres with well developed reporting systems the number of near incidents or incidents with no detrimental effect is high? A missed opportunity to learn and improve27Just CultureThe ROSIS experienceConsistency of error type across departments and across countriesCan learn from each otherAustraliaOctober 2012Joanne Cunningham28Learning from the ROSIS experienceWhere in the process are errors most likely to occur?Where in the process are errors detected?AustraliaOctober 2012Joanne Cunningham29Learning from the ROSIS experienceDo certain situations give rise to more or more serious errorsStage in the processTechniqueEquipmentWorking environmentAustraliaOctober 2012Joanne Cunningham30Just Culture - cautionIntroduction of a just disciplinary policy is not enough to bring about a just culture; the blame reflex is highly resilient

Derek Ross, Psychology Department TCD31Just Culture - cautionRequires an appreciation of the complexity of human behaviour and human error and how errors are managed

32Just Culture - cautionOnce introduced the report form and reporting can become the focusThe emphasis should be on the reasons for reportingTo learnTo reduce error potential33Reporting and Quality ImprovementAustraliaOctober 2012Joanne Cunningham34