1. The Emergence of a Just Culture Where We Were Where We May Be Where We Need to Go

2. Why Errors Occur in Healthcare  Patients as Individuals  Complexity  Coordination of Care with Other Departments  Lack of Standardized Processes  Communication Issues  Hierarchal Structures

3. Why Errors Occur in Healthcare  Autonomous disciplines – Silo thinking  Patient Acuity, Volume, and Workload  Hand-Offs  Staff Recruitment/Retention  Human characteristics  External Factors

4. External Factors Limiting Performance  Stress  Time pressures  Distraction  Goal Conflicts  Environment – noise  Level of training

5. Human Side of Medical Error  Long term memory vs Working memory  Chunking information  Storage and retrieval methods of information  Limitation of attention  Automatic and well established routines  Playing the odds – humans as risk takers; cutting corners

6. How Do Organizations Deal with Error?  Punitive Culture – prior to 1990’s  Blame Free Culture – mid to late 1990’s  Just Culture – new millennium

7. Characteristics of Punitive Cultures  Expectation was for perfect performance  Individual workers held solely accountable for patient outcomes  Workers involved in error were counseled or disciplined – who touched it last?  Disciplinary actions often based on amount of harm

8. Punitive Process for Dealing with Error  Focus on perceived individual weaknesses  Retraining, education, and vigilance  Improvement strategies – follow the five rights  Procedural violations unacceptable  Weed out “bad practitioners”

9. Effects of Punitive Environments  Errors driven underground  Fear of retribution, employment loss  Fear of license termination  Embarrassment  Workarounds developed  No reporting of near misses or errors waiting to happen  No news is good news mentality  Top down management of error

10. Why Punitive Environments Don’t Work  Change occurring from measures that involve sanctions, threats, or appeals is not sustainable  Threats and sanctions are de-motivating and inhibit safety progress  The precipitating causes of medical error are only the last links in the chain of events and are the least manageable  If punitive systems had worked, there would be no conversation

11. So why do we place blame?  Individuals as “free agents” – isolation  Captains of our own fate  Actions are seen as voluntary and within our control  Traditionally, we have blamed clinicians who have been involved in error with being careless or incompetent

12. “Experience suggests that the majority of unsafe acts - perhaps 90 percent or more- fall into the blameless category.” Managing the Risks of Organizational Accidents- Reason Is Blame Appropriate?

13. “The common reaction to an error in medical care is to blame the apparent perpetrator of the error. Blaming the person does not necessarily solve the problem; more likely, it merely changes the players in the error-conductive situation. The error will occur again, only to be associated with another provider. This will continue until the conditions that induce error are identified and changed.” Human Error in Medicine, Bogner, MS

14. Blame Free Culture  Acknowledged human fallibility  Perfect performance no longer achievable  Unsafe acts are usually result of slips or honest mistakes  Anyone can make a mistake  Vigilance alone cannot overcome error

15. Blame Free Process for Dealing with Error  Employee held harmless  Severity of error still taken into account  Investigation of systems issues  Implementation of process change

16. Unsafe Acts Were the actions as intended? Unauthorized Substance? Knowingly violated safe operating procedures? Pass substitution test? History of unsafe acts? Were the consequences as intended? Medical Conditions? Were procedures available, workable, intelligible and correct? Deficiencies in training and selection, or inexperienced? Blameless Error Substance Abuse without mitigation System induced violation Blameless Error, but corrective training or counseling indicated Possible reckless violation System Induced Error Sabotage, malevolent damage, suicide, etc. Substance Abuse with mitigation Possible Negligent Behavior CULPABLEGRAY AREABLAMELESS yes no yes no yes no yes no yes no yes

17. When faced with an accident or serious incident in which the unsafe acts of a particular person were implicated, we should perform the following mental test: Substitute the individual concerned for someone else. Could (or has) some well motivated, equally competent and comparably qualified individual make (or made) the same kind of error under those or similar circumstances? Substitution Test - Nelson Johnston

18. “A useful addition to the substitution test is to ask of the individual’s peers: ‘Given the circumstances that prevailed at the time, could you be sure that you would not have committed the same or similar type of unsafe act?’ If the answer is ‘probably not’ then blame is inappropriate

19. Effects of Blame Free  Increase in error reporting  Reporting of near miss situations  Punishment has no benefit to safety  Some lack of credibility or sense of justice

20. Just Culture  Rewards reporting  Values open communication  Risks openly discussed  Continued emphasis on systems  Stresses behavioral choices

21. Just Culture Process for Dealing with Error  Behavioral choices of staff are paramount  Acknowledgement of human fallibility  Understanding of certain at-risk behaviors  No tolerance for reckless behavior

22. Human Error Unintended human act that does not achieve the desired goal A planned action is not carried out as intended Use of a wrong plan No discipline because no intent

23. At-Risk Behaviors  To Drift is Human  We are programmed to drift into unsafe habits  We lose perception of the risk of everyday behaviors  We may believe the risk is justified

24. Why Do We Drift  Workers concerned with immediate consequences  Workers undervalue delayed consequences  Workers try to do more with less  Shortcuts evolve  We often reward at-risk behavior

25. Dealing With At-Risk Behavior  Uncover the reason  Address unrealistic procedural demands  Coach on making better behavioral choices  Decrease staff tolerance

26. Reckless Behavior  Worker always perceives the risk  Understands the risk is substantial  Behave intentionally with no justification  Knows that others are acting differently  Makes a conscious choice to disregard the risks for subjective reasons  Behavior is blameworthy

27. Effects of Just Cultures  Continued reporting of error and near miss  Continued system investigation  Continued process improvement  Peer pressure to develop, implement, and follow realistic standards of practice

28. Just Culture Accountability  Accountability for things you have control over  Managers – systems design, procedures  Employees – behavioral choices, highlighting unworkable procedures  Manager and peers as coach; observe daily behaviors  Eliminate rewards for at-risk behaviors  Focus is on how to prevent the next error