Medical errors and preventable incidents occur daily in healthcare organizations. By increasing the number of near misses and incidents reported, healthcare organizations can better understand safety challenges and prevent patient harm. Unfortunately, these harmful incidents often go unreported.
One notable health system recalls, “in a system that identifies fault and dispenses punishment, events tend to go underreported because the incentive is to hide information.” (1)
Traditionally, the standard solution is to hold individuals accountable for all errors that affect a patient under their care. However, the problem is rarely the fault of an individual; rather it is the fault of the health system as a whole. (2) When employees fear negative repercussions for their mistakes, they are less likely to report these wrongdoings.
A Just Culture recognizes that individuals should not be held accountable for system failings that are not in their control. (2) Even the most competent employees make mistakes or develop routine shortcuts. Having the ability to learn from these mistakes is fundamental for improving patient safety outcomes.
Basic Concepts for Establishing a Just Culture for Patient Safety
1. Managing system structure
Organizations must proactively assess system strengths and vulnerabilities and prioritize them for enhancement or improvement. A proactive approach is to search for potential breakdowns in safety and address those potential breakdowns to consistently ensure patient safety. (3)
It is important to manage system reliability by analyzing the factors that influence the rate of error. This includes implementing barriers or safeguards that prevent events before they happen. (4)
2. Understanding employee behavior
A key area of misunderstanding often occurs in how organizations define and respond to human error, at-risk behavior, and reckless behavior, which are the behaviors that can lead to risk and patient harm.
Human error involves inevitable mistakes that were committed unintentionally. However, at-risk behaviors are different from human errors. They are behavioral choices made when a person chooses to do something without ascertaining the consequences that may follow. Reckless behavior is a conscious disregard of risk. (5)
Organizations can solve these behaviors by keeping employees educated and informed, coaching to increase risk awareness, and removing system barriers to safe behavioral choices. (5)
3. Incident reporting and investigation
Managers should conduct incident investigation to learn about events that affect patient safety. This process can involve a procedure to answer the following questions:
- Why did it happen?
- What led to the incident?
- What were the causes?
- How did system structures play a role in the event?
Utilizing incident reporting software instead of tracking events on paper or Excel can help healthcare organizations better identify risks.
A software solution with customizable dashboards and analytics helps organizations gain insight into incidents and track reoccurring trends over time. Knowing which trends are likely to happen creates a simple path for leadership to establish action plans and adjust system structures.
Getting started with a just culture initiative includes ensuring that all members feel free to report errors. Creating a safe and transparent environment encourages reporting of mistakes and improves the overall care provided to patients.
Performance Health Partner’s Incident Reporting Software
Performance Health Partner’s Incident Reporting Software includes prevention, reporting, and post-event analysis to help your organization create a just culture.