Transcript Document

Just Culture
Establishing a safety learning
environment
Mary Coffey
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Just Culture
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Encouraging reporting of
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Incidents and near incidents
Unsafe practices
To enable learning
To establish a safety environment
Just Culture
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Human error is a fact of life
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Cannot be eliminated
Frequency can be reduced
How are human errors managed?
Just Culture
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Human error is a fact of life
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Blame
No blame
Just culture
Blame Culture
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It has to be someone’s fault
Disciplinary approach
An ‘easy’ option
Sometimes appropriate
Blame Culture
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Frequently not the fault of the
individual
Discourages reporting
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Failure to learn
Likelihood of repeat incidents
No blame Culture
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Not the individual but the system
Individuals reporting are not
subject to sanction/disciplinary
action
Can introduce complacency
Not always appropriate
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
Just Culture
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Human error is a fact of life
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Competent professionals make
mistakes
Develop shortcuts (routine violations)
Just Culture
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Human error is a fact of life
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Developing a learning rather than a
blaming culture
Learning from unsafe acts
Responding
Just Culture
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Trust is central to the development
of a just culture
We need to learn from our mistakes
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To understand the underlying causes
and address them
Just Culture
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Not always blame free
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A balance between the benefits of
learning from incidents and the need
for personal accountability
Repeated or careless behaviour
Transparent disciplinary policy
Just Culture
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Well established in Aviation, Nuclear
Industry and some areas of health
care
Just Culture
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The Danish Naviair experience
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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
Just Culture
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The Danish Naviair experience
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Previously unreported events
Identification of risks and trends
Opportunities to address latent safety
problems
Potential major improvement in safety
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GAIN working group
Just Culture
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Medical Event Reporting System for
Transfusion Medicine (MERS-TM)
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A standardised means of organised
data collection and analysis of
transfusion errors, adverse events and
near misses.
Just Culture
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Medical Event Reporting System for
Transfusion Medicine (MERS-TM)
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Effectiveness depends on the
willingness of individuals to report such
information
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David Marx
Just Culture
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Not about reporting but learning
from the reporting
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
Just Culture – Why?
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Organisational Culture in a helath
care setting impacts the performance
of the both organisation and the staff
Just Culture – Why?
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the single greatest impediment to
error prevention is …. that we punish
people for making mistakes”
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Dr. Lucian Leape briefing a US Congressional subcommittee
Just Culture – Why?
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Health care workers reluctant to
report
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Disciplinary based work environment
Failure on their part
Loyalty to colleagues
Just culture - Why?
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Modern radiotherapy is a very
complex process
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Technologically advanced and evolving
at a rapid pace
Just culture - Why?
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Modern radiotherapy is a very
complex process
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Requires the accurate application of
high technology planning and
treatment in an holistic environment
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A six week course of radiotherapy
requires over 1000 parameters to be
specified (ICRP 86)
Just Culture - Why?
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Modern radiotherapy is a very
complex process
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Encompasses technical, clinical, and
psychosocial management of individual
patients
Requires collaborative teamwork
It is expensive but subject to national
and local budgetary constraints
Just Culture - Why?
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Modern radiotherapy is a very
complex process
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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
Just Culture - Why?
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Modern radiotherapy is a very
complex process
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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
Just Culture
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The ROSIS experience
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Consistency of error type across
departments and across countries
Can learn from each other
Learning from the ROSIS
experience
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Where in the process are errors
most likely to occur?
Where in the process are errors
detected?
Learning from the ROSIS
experience
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Do certain situations give rise to
more or more serious errors
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Stage in the process
Technique
Equipment
Working environment
Just Culture - caution
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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
Just Culture - caution
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Requires an appreciation of the
complexity of human behaviour and
human error and how errors are
managed
Just Culture - caution
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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
Reporting and Quality Improvement
Report
Safer practice
analysis
Raising
awareness
feedback
Review of
effectiveness
Change of
practice