To adapt / quote the wonderful (both in skill and in the name of his latest book) poet Harry Baker…
I have spent a lifetime searching for the light and I don’t see a reason why that should stop now
You know that hideous feeling when something goes wrong. The sick feeling in the pit of your stomach. The absolute desire to turn back time and prevent what ever it was from happening. What do you need at that very point? You need kind eyes, a warm voice, and the space to breathe. You need a clarity, from someone else, that you cant find in yourself at that moment.
I wrote a post in 2015 when I thought that a just culture could be understood by putting people in boxes. I no long think that. A just culture is not as simple as saying that people are either erroneous, risky or reckless. This is with no disrespect to the people who have worked in just culture for years – I am sure they too would say to me that I am oversimplifying their concepts.
I have always had a problem with the language around a just culture, including the words ‘just culture’. I am not sure it sums up the culture or way of behaving that we know is needed in terms of patient safety. However, it is a terminology that is growing in its use throughout the NHS so rather than fight it I will work with it.
But. You don’t need to know that it was a mistake or error or whatever term you use – of course it was something you didn’t intend to do. Why on earth would it be. It is impossible to answer the question that someone in the heat of the moment might ask ‘why did you do that?’
Was it you being risky? yup, maybe. However, pause for a minute…..what led to you being risky? what pushed you to that point? what has been going on for months or years that have got you to this moment in time?
What the labelling does is completely focus our eyes and our blame squarely on the shoulders of the person.
A just culture is, for me, about understanding how important it is to respond to anything that has happened with a lack of judgement (and know that you have a number of biases that want you to make a judgement from the word go) and with a whole heap of kindness. It is about finding out what happened so we can all learn from it and make some adjustments if need be. It is about understanding the factors behind what happened, what were the circumstances that led to the action taken or choices made. It is about being honest, holding you hands up, not covering up, or hiding stuff. It is about everyone realising that it could easily be me. It is about helping people cope with what has happened so that they can put one foot in front of the other and carry on.
From Wonderful – by Harry Baker
May you see life as a show
and may the entry fee be empathy,
sat in the front row with an empty seat
for friends in need.
When you’re on form,
be generous
and spread that energy,
When you’re not sure
be gentle with yourself
and don’t forget to breathe.
PATIENT SAFETY NOW 