Just Culture
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1 Just Culture Establishing a safety learning environment Mary Coffey
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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
Transcript of Just Culture
1
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 Cannot be eliminated Frequency can be reduced
How are human errors managed?
Just Culture
Human error is a fact of life Blame No blame Just culture
Blame Culture
It has to be someone’s fault Disciplinary approach An ‘easy’ option Sometimes appropriate
Blame Culture
Frequently not the fault of the individual
Discourages reporting Failure to learn Likelihood of repeat incidents
No blame Culture
Not the individual but the system Individuals reporting are not
subject to sanction/disciplinary action
Can introduce complacency Not always appropriate
Just Culture
An 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 Reason
Just Culture
Human error is a fact of life Competent professionals make
mistakes Develop shortcuts (routine violations)
Just Culture
Human error is a fact of life Developing a learning rather than a
blaming culture Learning from unsafe acts Responding
Just Culture
Trust is central to the development of a just culture
We need to learn from our mistakes To understand the underlying causes
and address them
Just Culture
Not always blame free A balance between the benefits of
learning from incidents and the need for personal accountability
Repeated or careless behaviour Transparent disciplinary policy
Just Culture
Well established in Aviation, Nuclear Industry and some areas of health care
Just Culture
The Danish Naviair experience The introduction of non-punitive
reporting for aviation professionals in 2001
Number of reports in Danish air traffic control in the first year rose from approx. 15 per year to over 900
Just Culture
The Danish Naviair experience Previously unreported events Identification of risks and trends Opportunities to address latent safety
problems Potential major improvement in safety
GAIN working group
Just Culture
Medical 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.
Just Culture
Medical Event Reporting System for Transfusion Medicine (MERS-TM) Effectiveness depends on the
willingness of individuals to report such information
David Marx
Just Culture
Not about reporting but learning from the reporting
Just 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
Just Culture – Why?
Organisational Culture in a helath care setting impacts the performance of the both organisation and the staff
Just 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
Just Culture – Why?
Health care workers reluctant to report Disciplinary based work environment Failure on their part Loyalty to colleagues
Just culture - Why?
Modern radiotherapy is a very complex process Technologically advanced and evolving
at a rapid pace
Just culture - Why?
Modern radiotherapy is a very complex process Requires the accurate application of
high technology planning and treatment in an holistic environment
A six week course of radiotherapy requires over 1000 parameters to be specified (ICRP 86)
Just Culture - Why?
Modern radiotherapy is a very complex process Encompasses technical, clinical, and
psychosocial management of individual patients
Requires collaborative teamwork It is expensive but subject to national
and local budgetary constraints
Just Culture - Why?
Modern radiotherapy is a very complex process There are multiple processes, complex
calculations and many systems where failures can occur
Strongly dependent or influenced by human factors
High risk and error prone
Just Culture - Why?
Modern radiotherapy is a very complex process From 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 improve
Just Culture
The ROSIS experience Consistency of error type across
departments and across countries Can learn from each other
Learning from the ROSIS experience
Where in the process are errors most likely to occur?
Where in the process are errors detected?
Learning from the ROSIS experience
Do certain situations give rise to more or more serious errors Stage in the process Technique Equipment Working environment
Just Culture - caution
Introduction of a “just” disciplinary policy is not enough to bring about a just culture; the blame reflex is highly resilient
Derek Ross, Psychology Department TCD
Just Culture - caution
Requires an appreciation of the complexity of human behaviour and human error and how errors are managed
Just Culture - caution
Once introduced the report form and reporting can become the focus
The emphasis should be on the reasons for reportingTo learnTo reduce error potential
Reporting and Quality Improvement
Report
analysis
feedback
Change of practice
Review of effectiveness
Raising awareness
Safer practice
