Just Culture

To collect productive investigative data, we must promote a culture in which employees are willing to come forward in the interests of system safety. Yet, no one can afford to offer a “blame-free” system in which any conduct can be reported with impunity — as society rightly requires that some actions warrant disciplinary or enforcement action. It is the balancing of the need to learn from our mistakes and the need to take disciplinary action that motivates adoption of a just culture.

Brief yes/no questionnaire for senior managers assessing the organization’s commitment to a just culture.

Just Culture Algorithm from Outcome Engineering

This algorithm, developed by the Outcome Engineering company and David Marx, focuses on duty and mechanism of error.

According to this algorithm, there are three basic duties:

1. Duty to produce an outcome. If an individual knows the desired outcome and should be able to produce it (e.g., safe removal of an inflamed appendix), failure to do so represents breach of this duty.
2. Duty to follow a procedural rule. If the individual knows the proper procedure and it is possible to follow the rule (e.g., the procedure for inserting a central venous catheter), failure to do so represents a breach of this duty.
3. Duty to avoid causing unjustifiable risk or harm. Breach of this duty occurs when an individual intentionally harms the patient or acts recklessly.

If a duty has been breached, then the mechanism of the breach is identified. There are three identified causes:

1. Human error. This is an inadvertent act (“slip,” “lapse” or “mistake”).
2. At-risk behavior. Typically, this is a conscious drift from safe behavior, occurring when an individual believes that drift doesn’t cause any harm. An everyday example is the willingness of some drivers to roll through stop signs. Those drivers do not see that as risk-taking behavior, as, in their experience, nothing bad happened consequently.
3. Reckless behavior. In this case, the individual has chosen conduct that he knows poses a substantial and unjustifiable risk.

The response to an event (or near miss) is tied to the mechanism of error. An isolated human error is an opportunity to correct system weaknesses (e.g., confusing drug labels). The individual making the error should be consoled, rather than disciplined. At-risk behavior may also indicate a system vulnerability that should be fixed. However, the individual should be coached so that he understands the risks he has taken. Reckless behavior may be grounds for disciplinary action. The intent is to reduce the risk of future reckless conduct, and may include removing the individual from an organization.

Repetitive problems are often caused by system weaknesses, but sometimes are individual performance issues, particularly when coaching or additional training has not improved the problem. For example, repetitive human errors may be an indication that the individual is not capable of performing safely in his current job. Repetitive at-risk behaviors may be due to impairment (e.g., drug abuse) or unwillingness to follow proper protocols.

Just Culture Algorithm from the UK National Health Service

Incident decision tree adapted from the UK National Health Service’s National Patient Safety Agency (NPSA), and a Guide to Use (from the 2003 version). The NHS also issued Guidelines for Action Following Patient Safety Incidents. This algorithm focuses on identifying whether an individual was at least partially culpable for the event. The following is a brief summary of the decision tree, from the NPSA web site.

The Deliberate Harm Test

In most patient safety incidents the individual had the patient’s well being at heart.

However, in some cases the intent was to cause physical or emotional harm.

The Deliberate Harm Test asks questions to help identify or eliminate this possibility at the earliest possible stage.

The Physical/Mental Health Test

If intent to harm has been discounted, the Physical/Mental Health Test helps to identify whether the individual’s (not the patient's) ill health or substance abuse caused or contributed to the patient safety incident.

The Foresight Test

If intent to harm and incapacity have been discounted, the Foresight Test examines whether protocols and safe working practices were adhered to.

The Substitution Test

Finally, if protocols were not in place or proved ineffective, the Substitution Test helps to assess how a peer would have been likely to deal with the situation.

Rationale for Patient Safety and Quality Improvement Act of 2005 (PSQIA)

An excerpt from Sen. Edward Kennedy’s Senate Floor speech of July 21, 2005:

For even one American to die from an avoidable medical error is a tragedy. When thousands die every year from such errors, it is a national tragedy, and it is also a national disgrace, and an urgent call to action.

Five years ago, the Institute of Medicine reported that medical errors cause 98,000 deaths every year. That is an average of 268 deaths a day, every day. If errors in aviation killed 200 passengers a day in plane crashes, we would do more than simply encourage voluntary reporting. If errors at factories caused the deaths of 200 workers a day, we would demand more than corporate reports. We would require real changes.

Unfortunately, the culture of medicine has an expectation of infallibility in health professionals, and this unrealistic assumption has been reinforced by generations of medical training and medical practice.

When confronted with a mistake in health care, doctors and patients and citizens often ask, “How can there be errors without negligence?” Obviously, the fear of legal liability or embarrassment among peers and in the press leads to strong pressure to cover up mistakes.

In many cases, however, the inadequate design and implementation of health systems are responsible for the problem, including excessive work schedules and unreasonable time pressures.

We can do better. We can encourage the development of a safer health care system. We can learn important lessons from other dangerous fields, such as the aviation industry and the military, which are skillful in designing ways to provide maximum feasible safety.

The Institute of Medicine has called for strong action, and our proposal is responding to that call. The Institute’s series of reports on health care quality contain numerous recommendations for improving patient safety, and if we work together, we can make more of them a reality.

The Institute recommended that health care professionals should be encouraged to report medical errors, without fearing that their reports will be used against them. Our legislation implements this sensible recommendation by establishing patient safety organizations to analyze medical errors and recommend ways to avoid them in the future. The legislation also creates a legal privilege for information reported to the safety organizations, but still guaranteeing that original records, such as patients’ charts will remain accessible to patients.

Drawing the boundaries of this privilege requires a careful balance, and I believe the legislation has found that balance. The bill is intended to make medical professionals feel secure in reporting errors without fear of punishment, and it is right to do so. But the bill tries to do so carefully, so that it does not accidentally shield persons who have negligently or intentionally caused harm to patients. The legislation also upholds existing state laws on reporting patient safety information.