Just Culture - PSOW 2015

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  • ToErrIsHuman

    PatientSafetyYourSafetyOurSafety

  • CultureofSafety

    80%ofmedicalerrorsaresystemderived GoodpeoplesimplyworkingharderwillnotbesufficienttoovercomethehighcomplexityinherentinEMS.

    Errorswilloccur Thekeyistodesignsystemssothatharmdoesnotreachthepatient.

  • Reasons"SwissCheese"Model

    Reason,James.Humanerror:modelsandmanagement.BritishMedicalJournal2000;320:768770.

  • CultureofSafety

    Thebenefitofthisapproachtomanagingbehavioristhattheprocessisupfrontandtransparenttothestaff,whichhelpstoachievetrust.

    Risksbecomeidentified,recklessbehaviorisnttolerated,andultimatelytheorganizationissafer.

    Inpracticalterms,todayyouare3xmorelikelytobeinvolvedinaMVCand1,000xmorelikelytobeinvolvedinamedicalerrorthaninanaviationrelatedincident,dueinparttothisculturalshift.

  • AnIntroductiontoJustCulture

    The single greatest impediment to error prevention in the medical industry is

    that we punish people for making mistakes

    Dr. Lucian LeapeProfessor, Harvard School of Public Health

    Testimony before Congress on Health Care Quality Improvement

  • SafeCulture Thefirstandpossiblymostimportantstepinpromotingasafe

    cultureistheestablishmentofjustice. JustCulture Asystemofsharedaccountability Theorganizationisresponsibleforsafesystemandprocessdesign Andemployeesareresponsibleforsafechoicesandbehaviors

    Thisshiftsanorganizationawayfromablameculture. Why? Becausetodesignsafety,theorganizationneedsfeedbackfrom

    users(employees). Togivefeedback,employeesneedtrust. Anorganizationcanestablishthistrustthroughaconsistentandfair

    approachtomanagingemployeebehaviors.

  • EstablishmentofaJustCulture

  • EstablishmentofaJustCulture OutcomeEngineeringofPlato,Texasdefinesthesethree

    behaviorsasfollows: HumanError:

    Aninadvertentaction;inadvertentlydoingotherthatwhatshouldhavebeendone;slip,lapse,mistake.

    Productofcurrentsystemdesignandbehavioralchoices AtRiskBehavior:

    Abehavioralchoicethatincreasesriskwhereriskisnotrecognized,orismistakenlybelievedtobejustified.

    Achoice,riskbelievedinsignificantorjustified RecklessBehavior:

    Abehavioralchoicetoconsciouslydisregardasubstantialandunjustifiablerisk.

  • EstablishmentofaJustCulture

    HumanError: Aninadvertentaction;inadvertentlydoingotherthatwhatshouldhavebeendone;slip,lapse,mistake.

    Productofcurrentsystemdesignandbehavioralchoices

    Managethroughchangesin: Processes&Procedures Design Training

    Console

  • EstablishmentofaJustCulture

    AtRiskBehavior: A behavioralchoicethatincreasesriskwhereriskisnotrecognized,orismistakenlybelievedtobejustified.

    Achoice,riskbelievedinsignificantorjustified Managethrough:

    Removingincentivesforatriskbehaviors Creatingincentivesforhealthybehaviors Increasingsituationalawareness

    Coach

  • RequiresAChangeinCulture

    Treateverydrugadministrationasifitswrongandwillkillthepatient

    JohnNance

    SuggestedMeds: Narcotics,toincludeKetamine Epi1:1,000vsEpi1:10,000 MagSulfate AnyPediatricDose Rarelyusedmedications[Diltiazem] AllCCPmedications

  • EstablishmentofaJustCulture

    RecklessBehavior: Abehavioralchoicetoconsciouslydisregardasubstantialandunjustifiablerisk

    Managethrough: Remedialaction Punitiveaction

    Discipline

  • AccountabilityforOurBehaviorsHumanError AtRiskBehavior RecklessBehavior

    Inadvertentaction:slip,lapse,mistake

    Achoice:risknotrecognizedorbelievedjustified

    Consciousdisregardofunreasonablerisk

    Managethroughchangesin: Processes Procedures Training Design Environment

    Managethrough: Removeincentives

    foratriskbehaviors

    Createincentivesforhealthybehaviors

    Increasesituationalawareness

    Managethrough: Remedialaction Punitiveaction

    Console Coach Discipline/Sanction

  • Whatdoyousee?

  • JustCulture NotBlameAlsonotcarefree

    Ajustculturerecognizesthatindividualpractitionersshouldnotbeheldaccountableforsystemfailingsoverwhichtheyhavenocontrol.

    Ajustculturealsorecognizesmanyerrorsrepresentpredictableinteractionsbetweenhumanoperatorsandthesystemsinwhichtheywork;andrecognizesthatcompetentprofessionalsmakemistakes.

    Alsoacknowledgesthatevencompetentprofessionalswilldevelopunhealthynorms(shortcuts,routineruleviolations).

    Ajustculturehaszerotolerance forrecklessbehavior.

  • WrongMedicationDoseHumanError AtRiskBehavior RecklessBehavior

    Inadvertentaction:slip,lapse,mistake

    Achoice:risknotrecognizedorbelievedjustified

    Consciousdisregardofunreasonablerisk

    Idrewup4mgandgaveitIV,thenimmediatelyrealizedthatitshouldhavebeen0.4mg

    Iwouldhavedoublecheckedwithmypartner,butshewasoutgettingsupplies,andIwantedtogetthepatienttreated

    Ihaveeverythingmemorizedanddontrelyoncheatsheetsandcanttrustanothermedic

    Console Coach Discipline/Sanction

  • WrongMedicationDoseHumanError AtRiskBehavior RecklessBehavior

    Inadvertentaction:slip,lapse,mistake

    Achoice:risknotrecognizedorbelievedjustified

    Consciousdisregardofunreasonablerisk

    Idrewup4mgandgaveitIV,thenimmediatelyrealizedthatitshouldhavebeen0.4mg

    Iwouldhavedoublecheckedwithmypartner,butshewasoutgettingsupplies,andIwantedtogetthepatienttreated

    Ihaveeverythingmemorizedanddontrelyoncheatsheetsandcanttrustanothermedic

    Console Coach Discipline/Sanction

  • WrongMedicationDoseHumanError AtRiskBehavior RecklessBehavior

    Inadvertentaction:slip,lapse,mistake

    Achoice:risknotrecognizedorbelievedjustified

    Consciousdisregardofunreasonablerisk

    Idrewup4mgandgaveitIV,thenimmediatelyrealizedthatitshouldhavebeen0.4mg

    Iwouldhavedoublecheckedwithmypartner,butshewasoutgettingsupplies,andIwantedtogetthepatienttreated

    Ihaveeverythingmemorizedanddontrelyoncheatsheetsandcanttrustanothermedic

    Console Coach Discipline/Sanction

  • RSI:ParalysisWithoutSedationHumanError AtRiskBehavior RecklessBehavior

    Inadvertentaction:slip,lapse,mistake

    Achoice:risknotrecognizedorbelievedjustified

    Consciousdisregardofunreasonablerisk

    3amcall,verybusynight,Iwastired

    Patienthadaheadinjuryandwasunconscioussodidntneedsedation

    PatientisdementedandwontrememberanywayorIveneverhadapatientcomplain

    Console Coach Discipline/Sanction

  • RSI:ParalysisWithoutSedationHumanError AtRiskBehavior RecklessBehavior

    Inadvertentaction:slip,lapse,mistake

    Achoice:risknotrecognizedorbelievedjustified

    Consciousdisregardofunreasonablerisk

    3amcall,verybusynight,Iwastired

    Patienthadaheadinjuryandwasunconscioussodidntneedsedation

    PatientisdementedandwontrememberanywayorIveneverhadapatientcomplain

    Console Coach Discipline/Sanction

  • RSI:ParalysisWithoutSedationHumanError AtRiskBehavior RecklessBehavior

    Inadvertentaction:slip,lapse,mistake

    Achoice:risknotrecognizedorbelievedjustified

    Consciousdisregardofunreasonablerisk

    3amcall,verybusynight,Iwastired

    Patienthadaheadinjuryandwasunconscioussodidntneedsedation

    PatientisdementedandwontrememberanywayorIveneverhadapatientcomplain

    Console Coach Discipline/Sanction

  • AccountabilityforOurBehaviorsHumanError AtRiskBehavior RecklessBehavior

    Inadvertentaction:slip,lapse,mistake

    Achoice:risknotrecognizedorbelievedjustified

    Consciousdisregardofunreasonablerisk

    Managethroughchangesin: Processes Procedures Training Design Environment

    Managethrough: Removeincentives

    foratriskbehaviors

    Createincentivesforhealthybehaviors

    Increasesituationalawareness

    Managethrough: Remedialaction Punitiveaction

    Console Coach Discipline/Sanction

  • AssumeGoodIntent

    JustCulture NotBlame.Alsonotcarefree.Ajustculturehaszerotolerance forrecklessbehavior.