ROSIS - Working Towards Safer Healthcare Delivery Dublin, 11th - 14th May 2009 Just Culture Establishing a safety learning environment Mary Coffey Joanne Cunningham

Just Culture Encouraging reporting of To enable learning Australia October 2012 Just Culture Encouraging reporting of Incidents and near incidents Unsafe practices To enable learning To establish a safety environment Joanne Cunningham

Just Culture Human error is a fact of life Australia October 2012 Just Culture Human error is a fact of life Cannot be eliminated Frequency can be reduced How are human errors managed? Joanne Cunningham

Just Culture Human error is a fact of life Blame No blame Just culture Australia October 2012 Just Culture Human error is a fact of life Blame No blame Just culture Joanne Cunningham

Blame Culture It has to be someone’s fault Disciplinary approach Australia October 2012 Blame Culture It has to be someone’s fault Disciplinary approach An ‘easy’ option Sometimes appropriate Joanne Cunningham

Blame Culture Frequently not the fault of the individual Australia October 2012 Blame Culture Frequently not the fault of the individual Discourages reporting Failure to learn Likelihood of repeat incidents Joanne Cunningham

No blame Culture Not the individual but the system Australia October 2012 No blame Culture Not the individual but the system Individuals reporting are not subject to sanction/disciplinary action Can introduce complacency Not always appropriate Joanne Cunningham

Australia October 2012 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 Joanne Cunningham

Just Culture Human error is a fact of life Australia October 2012 Just Culture Human error is a fact of life Competent professionals make mistakes Develop shortcuts (routine violations) Joanne Cunningham

Just Culture Human error is a fact of life Australia October 2012 Just Culture Human error is a fact of life Developing a learning rather than a blaming culture Learning from unsafe acts Responding Joanne Cunningham

Just Culture Trust is central to the development of a just culture Australia October 2012 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 Joanne Cunningham

Just Culture Not always blame free Australia October 2012 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 Joanne Cunningham

Australia October 2012 Just Culture Well established in Aviation, Nuclear Industry and some areas of health care Joanne Cunningham

Just Culture The Danish Naviair experience Australia October 2012 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 Joanne Cunningham

Just Culture The Danish Naviair experience Australia October 2012 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 Joanne Cunningham

Australia October 2012 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. Joanne Cunningham

Australia October 2012 Just Culture Medical Event Reporting System for Transfusion Medicine (MERS-TM) Effectiveness depends on the willingness of individuals to report such information David Marx Joanne Cunningham

Just Culture Not about reporting but learning from the reporting Australia October 2012 Just Culture Not about reporting but learning from the reporting Joanne Cunningham

Australia October 2012 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 Joanne Cunningham

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

Australia October 2012 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 Joanne Cunningham

Just Culture – Why? Health care workers reluctant to report Australia October 2012 Just Culture – Why? Health care workers reluctant to report Disciplinary based work environment Failure on their part Loyalty to colleagues Joanne Cunningham

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

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) 24

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 25

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 26

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 27

Just Culture The ROSIS experience Australia October 2012 Just Culture The ROSIS experience Consistency of error type across departments and across countries Can learn from each other Joanne Cunningham

Learning from the ROSIS experience Australia October 2012 Learning from the ROSIS experience Where in the process are errors most likely to occur? Where in the process are errors detected? Joanne Cunningham

Learning from the ROSIS experience Australia October 2012 Learning from the ROSIS experience Do certain situations give rise to more or more serious errors Stage in the process Technique Equipment Working environment Joanne Cunningham

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 31

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

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 33

Reporting and Quality Improvement Australia October 2012 Reporting and Quality Improvement Report analysis feedback Change of practice Review of effectiveness Raising awareness Safer practice Joanne Cunningham