Just Culture

1. Just Culture Establishing a safety learning environment Mary Coffey

2. Just Culture • Encouraging reporting of • Incidents and near incidents • Unsafe practices • To enable learning • To establish a safety environment

3. Just Culture • Human error is a fact of life • Cannot be eliminated • Frequency can be reduced • How are human errors managed?

4. Just Culture • Human error is a fact of life • Blame • No blame • Just culture

5. Blame Culture • It has to be someone’s fault • Disciplinary approach • An ‘easy’ option • Sometimes appropriate

6. Blame Culture • Frequently not the fault of the individual • Discourages reporting • Failure to learn • Likelihood of repeat incidents

7. No blame Culture • Not the individual but the system • Individuals reporting are not subject to sanction/disciplinary action • Can introduce complacency • Not always appropriate

8. 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

9. Just Culture • Human error is a fact of life • Competent professionals make mistakes • Develop shortcuts (routine violations)

10. Just Culture • Human error is a fact of life • Developing a learning rather than a blaming culture • Learning from unsafe acts • Responding

11. 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

12. 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

13. Just Culture • Well established in Aviation, Nuclear Industry and some areas of health care

14. 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

15. 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

16. 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.

17. Just Culture • Medical Event Reporting System for Transfusion Medicine (MERS-TM) • Effectiveness depends on the willingness of individuals to report such information • David Marx

18. Just Culture • Not about reporting but learning from the reporting

19. 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

20. Just Culture – Why? • Organisational Culture in a helath care setting impacts the performance of the both organisation and the staff

21. 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

22. Just Culture – Why? • Health care workers reluctant to report • Disciplinary based work environment • Failure on their part • Loyalty to colleagues

23. Just culture - Why? • Modern radiotherapy is a very complex process • Technologically advanced and evolving at a rapid pace

24. 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)

25. 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

26. 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

27. 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

28. Just Culture • The ROSIS experience • Consistency of error type across departments and across countries • Can learn from each other

29. Learning from the ROSIS experience • Where in the process are errors most likely to occur? • Where in the process are errors detected?

30. Learning from the ROSIS experience • Do certain situations give rise to more or more serious errors • Stage in the process • Technique • Equipment • Working environment

31. 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

32. Just Culture - caution • Requires an appreciation of the complexity of human behaviour and human error and how errors are managed

33. Just Culture - caution • Once introduced the report form and reporting can become the focus • The emphasis should be on the reasons for reporting • To learn • To reduce error potential

34. Reporting and Quality Improvement