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Just Culture
Establishing a safety learning environment
Mary Coffey
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Just Culture
Encouraging reporting of Incidents and near incidents Unsafe practices
To enable learning To establish a safety environment
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Just Culture
Human error is a fact of life Cannot be eliminated Frequency can be reduced
How are human errors managed?
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Just Culture
Human error is a fact of life Blame No blame Just culture
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Blame Culture
It has to be someone’s fault Disciplinary approach An ‘easy’ option Sometimes appropriate
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Blame Culture
Frequently not the fault of the individual
Discourages reporting Failure to learn Likelihood of repeat incidents
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No blame Culture
Not the individual but the system Individuals reporting are not
subject to sanction/disciplinary action
Can introduce complacency Not always appropriate
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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
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Just Culture
Human error is a fact of life Competent professionals make
mistakes Develop shortcuts (routine violations)
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Just Culture
Human error is a fact of life Developing a learning rather than a
blaming culture Learning from unsafe acts Responding
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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
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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
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Just Culture
Well established in Aviation, Nuclear Industry and some areas of health care
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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
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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
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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.
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Just Culture
Medical Event Reporting System for Transfusion Medicine (MERS-TM) Effectiveness depends on the
willingness of individuals to report such information
David Marx
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Just Culture
Not about reporting but learning from the reporting
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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
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Just Culture – Why?
Organisational Culture in a helath care setting impacts the performance of the both organisation and the staff
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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
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Just Culture – Why?
Health care workers reluctant to report Disciplinary based work environment Failure on their part Loyalty to colleagues
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Just culture - Why?
Modern radiotherapy is a very complex process Technologically advanced and evolving
at a rapid pace
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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)
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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
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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
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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
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Just Culture
The ROSIS experience Consistency of error type across
departments and across countries Can learn from each other
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Learning from the ROSIS experience
Where in the process are errors most likely to occur?
Where in the process are errors detected?
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Learning from the ROSIS experience
Do certain situations give rise to more or more serious errors Stage in the process Technique Equipment Working environment
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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
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Just Culture - caution
Requires an appreciation of the complexity of human behaviour and human error and how errors are managed
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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
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Reporting and Quality Improvement
Report
analysis
feedback
Change of practice
Review of effectiveness
Raising awareness
Safer practice