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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

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

21. 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

22. 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

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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

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

33. 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

34. 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