Re(think) Patient Safety Series – Blog 2

  1. Learning from incident reports and investigations
  2. Embedding the just culture for safety
  3. Delivering the right solutions and closing the implementation gap between theory and practice

Blog 2 continues the series on Re(think) Patient Safety which are covering the three issues above.  This blog will cover the issue of embedding the just culture for safety.

The single greatest impediment to error prevention is that we punish people for making mistakes” – Lucian Leape 1997 (in a speech to the US Congress)

There is a myth in patient safety – that we at some point advocated the ‘blame free’ approach to safety – in fact we only advocated the fair blame approach – some call the just culture for safety.  The thing is this is not well understood. There is an urgent and vital need for everyone to understand the just culture; where people are supported when things go wrong but that there is also accountability for risky and reckless behaviour. The lessons from the just culture community should inform our approach to regulation and human resources.  Human fallibility and human error are inevitable and we need to care for the people who are involved.  In fact there are three important things we should all agree on:

  • The best people can make the worst mistakes
  • Systems will never be perfect
  • Human beings will never be perfect

Agreeing on this will mean that we will be able to design our work processes based on a preoccupation with failure instead of counting the things we failed to stop; and one which support a resilient system where errors are kept small and where systems are designed to allow for human adaptability and flexibility.

If we have the right culture in healthcare we should always:

  • expect to operate on the wrong leg
  • expect to give the wrong dose of a drug
  • expect to give a patient the drug they are allergic to

….if we do that then we will embed a preoccupation with failure.  Which just might mean that we are safer because of it.  But if we keep perpetuating the fear of blame we will never be able to do this.  Let’s start with stopping with the avoidable versus unavoidable debate; Up and down the country there are all day meetings where individuals (mainly nurses) stop what they are doing and nervously trickle into a room clutching mounds of paper and sweaty hands to argue their case for whether the incident they were involved in was avoidable or unavoidable. Judge and jury sit and debate with people desperate to be put in the unavoidable camp.

– The Quote from Robert Montgomery comes to mind…Are you really listening or are you just waiting your turn to talk?

This at best is distracting and at worst perpetuates the blame and fear culture. People feel that they can’t deliver the bad news or problems without retribution. This approach is too simplistic and stifles people who need to share the problems in order to identify the potential learning and solutions.  Let’s be kinder to each other. Let’s be kinder to ourselves. Yes people are imperfect but they need help to get through life and work.  You have to fail a lot before you get it right but we don’t give people permission to admit this.  Judgement silences things, turns learning into a secret. Empathy enables that secret to be shared.  The just culture addresses all of these issues.  This means:

  • People who make an error (human error) are cared for and supported
  • People who don’t adhere to policies (risky behaviour) are asked first before being judged
  • People who intentionally put their patients or themselves at risk (reckless behaviour) are accountable for their actions

What can we do to re(think) the safety culture?

Review your current disciplinary policy.  Lets ensure it accounts for when incidents are investigated that there is an understanding of human factors and the just culture.  The key issue is to ensure that learning from the events outweigh the deterrent effect of punishment and your staff feel able to speak out, raise concerns and report incidents.