Just Culture in Healthcare
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and Legal Process
The Necessary Change
“People make errors, which lead to accidents. Accidents lead to deaths. The standard solution is to blame the people involved. If we find out who made the errors and punish them, we solve the problem, right? Wrong. The problem is seldom the fault of an individual; it is the fault of the system. Change the people without changing the system and the problems will continue.” Don Norman Author, the Design of Everyday Things
Healthcare is a risky business. While the maxim ‘first, do no harm’ is a fundamentally important precept, and the aim of a ‘zero harm’ care environment is a laudable one, no healthcare system will ever be completely harm free. How the needs and interests of patients and professionals are managed in the aftermath of healthcare harm is therefore a significant, but largely overlooked, aspect of care quality.
Medication errors continue to be a concern of healthcare providers and the public, in particular how to prevent harm from medication mistakes. Many healthcare workers are afraid to report errors for fear of retribution including the loss of professional licensure and even imprisonment. For example if a healthcare professional makes an error that causes no harm we consider them to be lucky. If another person makes the same error resulting in injury to a patient we consider them to be blameworthy and disciplinary action may follow. The more severe the outcome, the more blameworthy the person becomes. This is a flawed system based upon the notion that we can totally control our outcomes.
Creating a Just Culture
Honesty and a willingness to learn from error are fundamental to the creation of a Just Culture. Regrettably, however most people still work in systems where individual blame and recrimination are the norm and where deep learning from error is still the exception.
Many errors go unreported by healthcare workers; The major reason errors are not reported is that self-reporting will result in repercussions. Healthcare workers may suffer worry, guilt, anxiety, self-doubt, blame, and depression following serious errors, both for themselves (for disciplinary actions) and for the patient who has been harmed.
Disciplining healthcare workers for honest mistakes is counterproductive, but the failure to discipline workers who are involved in repetitive errors poses a danger to patients. A blame-free culture holds no one accountable and any conduct can be reported without any consequences. Finding a balance between punishment and blamelessness is the basis for developing a Just Culture. Most healthcare workers are silent, instead of admitting their mistake and discussing it openly with peers. This can result in further patient harm if the system causing the mistake is not identified and fixed; thus self-denial may have a negative impact on patient care outcomes. As a result, healthcare leaders, in collaboration with others, must put systems in place that serve to prevent errors while promoting a “Just Culture” way of managing performance and outcomes. This culture must exist across disciplines and departments.
Just Culture strikes a balance between punishment and blamelessness. It fosters an environment of openness and fairness in order to facilitate the honest reporting of errors. Just Culture identifies three types of behavioral choices: human error, at-risk behavior, and reckless behavior. It establishes a fair and transparent process for evaluating errors and determining a course of action based on the quality of the behavior and not on the outcome of the error. . By designing safe systems that work proactively, a Just Culture is prepared to assess the daily risks inherent in its operations. This leads to maximum reliability and the prevention of future events.
Just Culture is also about ensuring that a company has a learning culture. When things go wrong and we want to learn from error and incidents, understanding the differences between human error, risky behaviour and reckless behaviour is vital as well as understanding the natural bias we are all subject to in particular outcome and hindsight bias.
Just Culture is a model of shared accountability where both management and staff are held accountable. This model can be integrated into any healthcare setting by classifying behaviors associated with errors and providing consistent follow-up with employees.
- Out of the pain must come healing Case presented by Suzette Woodward, NHS
- HMRI: Experiences of enforcing Health and Safety Law by Patrick Talbot, Office of Rail and Road
- Making judgements IN (and ON) the messy world of medicine
- Exploring Healthcare Harm
- Healthcare's Just Culture Journey: A Long and Winding Road by Martin Bromiley, Clinical Human Factors Group
- Just Culture: The Movie This film documents the amazing transformation in one organization —
Mersey Care, an NHS mental health trust in the UK.