Transcript Document
Just Culture
Establishing a safety learning
environment
Mary Coffey
1
Just Culture
Encouraging reporting of
Incidents and near incidents
Unsafe practices
To enable learning
To establish a safety environment
Just Culture
Human error is a fact of life
Cannot be eliminated
Frequency can be reduced
How are human errors managed?
Just Culture
Human error is a fact of life
Blame
No blame
Just culture
Blame Culture
It has to be someone’s fault
Disciplinary approach
An ‘easy’ option
Sometimes appropriate
Blame Culture
Frequently not the fault of the
individual
Discourages reporting
Failure to learn
Likelihood of repeat incidents
No blame Culture
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
Human error is a fact of life
Competent professionals make
mistakes
Develop shortcuts (routine violations)
Just Culture
Human error is a fact of life
Developing a learning rather than a
blaming culture
Learning from unsafe acts
Responding
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
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
Just Culture
Well established in Aviation, Nuclear
Industry and some areas of health
care
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
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
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.
Just Culture
Medical Event Reporting System for
Transfusion Medicine (MERS-TM)
Effectiveness depends on the
willingness of individuals to report such
information
David Marx
Just Culture
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?
Organisational Culture in a helath
care setting impacts the performance
of the both organisation and the staff
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
Just Culture – Why?
Health care workers reluctant to
report
Disciplinary based work environment
Failure on their part
Loyalty to colleagues
Just culture - Why?
Modern radiotherapy is a very
complex process
Technologically advanced and evolving
at a rapid pace
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)
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
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
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
Just Culture
The ROSIS experience
Consistency of error type across
departments and across countries
Can learn from each other
Learning from the ROSIS
experience
Where in the process are errors
most likely to occur?
Where in the process are errors
detected?
Learning from the ROSIS
experience
Do certain situations give rise to
more or more serious errors
Stage in the process
Technique
Equipment
Working environment
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
Just Culture - caution
Requires an appreciation of the
complexity of human behaviour and
human error and how errors are
managed
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
Reporting and Quality Improvement
Report
Safer practice
analysis
Raising
awareness
feedback
Review of
effectiveness
Change of
practice