Recommendation: Follow Covenant Health policy. Consult HR, Medical Affairs. Consider remedial actions &/or discipline: increased support/supervision; targeted education; corrective training; adjusted duties. Actions beyond remedial up to and including: contact of relevant regulatory bodies, suspension, referral to police and disciplinary processes. Request an administrative review. Broad investigation required to determine how and why patients were not protected from the individual's actions. If system factors identified: request a system level review. (Policy III-45) Responding to Adverse Events, Close Calls and Hazards).

END

HERE

Not every incident or report of error will require review using this just culture guide, but it can be useful if the investigation of an incident begins to suggest a concern about an individual's actions or behaviour. This guide supports decision-making about whether a staff member involved in a patient safety incident requires specific individual support or intervention to work safely: most patient safety issues involve multiple factors, both human and system-related.

The Just Culture Guide is a reference and communication tool to help management, staff, patients/residents and families understand how the appropriate response to a staff member involved in an incident can and should differ based on context and circumstance during which an error was made.

Action singling out an individual is rarely appropriate. Patient safety issues usually involve contributing system and human factors.

In addition to supporting staff, using the guide helps protect patients by removing the tendency to treat broader patient safety issues as individual issues.

Please note - the Just Culture Guide: • is not a replacement for an investigation of a patient

safety incident. Only a full investigation can identifythe underlying causes that need to be acted on toreduce the risk of future incidents.

• can be used at any point of an investigation, but theguide may need to be revisited as more informationbecomes available.

• does not replace HR advice and should be used inconjunction with Covenant Health Just Culture policy.

• can only be used to take one action (or failure to act)through the guide at a time. If multiple actions areinvolved in an incident they must be consideredseparately.

1. Was there any intention to cause harm? Werethe actions (not the outcome) as intended?

Start here - Q1. deliberate harm test

Yes

Recommendation: Action directed at the individual may not be appropriate; follow organizational guidance, which is likely to include senior HR advice on what degree of mitigation applies. The patient safety incident investigation should indicate the wider actions needed to improve safety for future patients. If system factors identified, request a system level review.

Yes

Recommendation: Follow organizational guidance for appropriate management action. This could involve individual training, performance management, competency assessments, changes to role or increased supervision, and may require relevant regulatory bodies to be contacted, staff suspension and disciplinary processes. The patient safety incident investigation should indicate the wider actions needed to improve safety for future patients.

Just Culture guideTo support consistent, constructive and fair evaluation of the actions of staff involved in patient safety incidents

Recommendation: Initiate operational or fact-finding review. Options: Educational Review; consider Failure Mode Effect Analysis (FMEA) or process mapping. Action singling out the individual is unlikely to be appropriate; the patient safety incident investigation should indicate the broader steps needed to improve safety for future patients. These steps may include, but not be limited to, the individual. Consult Human Resources; OH&S. EN

D HE

RE

If No

to a

ny

Recommendation: Request a system level review. Action singling out the individual is unlikely to be appropriate; the patient safety incident investigation should indicate the wider steps needed to improve safety for future patients. EN

D HE

RE

4a. Are there indications that other individuals from the same peer group, with comparable experience and qualifications, would behave in the same way in similar circumstances?

4b. Were there deficiencies in training, education or experience?

4c. Were there deficiencies in the supervision that normally should be provided? If

Yes t

o an

y

if No to all, go to: Q5. mitigating circumstances

5a. Were there any significant mitigating circumstances?

if No,

Recommendation: Consult Human Resources; Medical Affairs. Follow Covenant Health substance abuse at work guidance. Access support resources: Employee & Family Assistance &/or Spiritual Care. Referral to OH&S. Provide sick leave. Broad investigation required to understand if substance abuse could have been recognized and addressed earlier.

END

HERE

END

HERE

END

HERE

2a. Are there indications of substance abuse?

2b. Are there indications of physical ill health?

2c. Are there indications of mental ill health?

if NO to all, go to: Q3. foresight test3a. Are there agreed protocols/accepted practice in place

that apply to the action/omission in question?

3b. Were the protocols/accepted practice workable and in routine use?

3c. Did the individual knowingly depart from these protocols?

if YES to all, go to: Q4. substitution test

if NO, go to next question: Q2. health test

Yes

Recommendation: Follow Covenant Health policy and guidance for health issues affecting work, ie referrals to occupational health, Employee & Family Assistance. Consider the impact of the individual's health and wellbeing on their actions at the time of the incident.

END

HERE

Yes

Based on the work of Professor James Reason and the National Patient Safety Agency’s Incident Decision Tree and improvement.nhs.uk

Q1.

Q2.

Q3.

Q4.

Q5.

see below