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1 Just Culture Establishing a safety learning environment Mary Coffey.

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1 1 Just Culture Establishing a safety learning environment Mary Coffey

2 Just Culture Encouraging reporting of Incidents and near incidents Unsafe practices To enable learning To establish a safety environment

3 Just Culture Human error is a fact of life Cannot be eliminated Frequency can be reduced How are human errors managed?

4 Just Culture Human error is a fact of life Blame No blame Just culture

5 Blame Culture It has to be someones fault Disciplinary approach An easy option Sometimes appropriate

6 Blame Culture Frequently not the fault of the individual Discourages reporting Failure to learn Likelihood of repeat incidents

7 No blame Culture Not the individual but the system Individuals reporting are not subject to sanction/disciplinary action Can introduce complacency Not always appropriate

8 Just Culture An atmosphere of trust in which people are encouraged, even rewarded, for providing essential safety-related information… but in which they are also clear about where the line must be drawn between acceptable and unacceptable behavior. Prof. James Reason

9 Just Culture Human error is a fact of life Competent professionals make mistakes Develop shortcuts (routine violations)

10 Just Culture Human error is a fact of life Developing a learning rather than a blaming culture Learning from unsafe acts Responding

11 Just Culture Trust is central to the development of a just culture We need to learn from our mistakes To understand the underlying causes and address them

12 Just Culture Not always blame free A balance between the benefits of learning from incidents and the need for personal accountability Repeated or careless behaviour Transparent disciplinary policy

13 Just Culture Well established in Aviation, Nuclear Industry and some areas of health care

14 Just Culture The Danish Naviair experience The introduction of non-punitive reporting for aviation professionals in 2001 Number of reports in Danish air traffic control in the first year rose from approx. 15 per year to over 900

15 Just Culture The Danish Naviair experience Previously unreported events Identification of risks and trends Opportunities to address latent safety problems Potential major improvement in safety GAIN working group

16 Just Culture Medical Event Reporting System for Transfusion Medicine (MERS-TM) A standardised means of organised data collection and analysis of transfusion errors, adverse events and near misses.

17 Just Culture Medical Event Reporting System for Transfusion Medicine (MERS-TM) Effectiveness depends on the willingness of individuals to report such information David Marx

18 Just Culture Not about reporting but learning from the reporting

19 Just Culture – Why? … one million people injured by errors in treatment at hospitals each year in the US, with 120,000 people dying from those injuries

20 Just Culture – Why? Organisational Culture in a helath care setting impacts the performance of the both organisation and the staff

21 Just Culture – Why? the single greatest impediment to error prevention is …. that we punish people for making mistakes Dr. Lucian Leape briefing a US Congressional subcommittee

22 Just Culture – Why? Health care workers reluctant to report Disciplinary based work environment Failure on their part Loyalty to colleagues

23 Just culture - Why? Modern radiotherapy is a very complex process Technologically advanced and evolving at a rapid pace

24 Just culture - Why? Modern radiotherapy is a very complex process Requires the accurate application of high technology planning and treatment in an holistic environment A six week course of radiotherapy requires over 1000 parameters to be specified (ICRP 86)

25 Just Culture - Why? Modern radiotherapy is a very complex process Encompasses technical, clinical, and psychosocial management of individual patients Requires collaborative teamwork It is expensive but subject to national and local budgetary constraints

26 Just Culture - Why? Modern radiotherapy is a very complex process There are multiple processes, complex calculations and many systems where failures can occur Strongly dependent or influenced by human factors High risk and error prone

27 Just Culture - Why? Modern radiotherapy is a very complex process From experience in centres with well developed reporting systems the number of near incidents or incidents with no detrimental effect is high ? A missed opportunity to learn and improve

28 Just Culture The ROSIS experience Consistency of error type across departments and across countries Can learn from each other

29 Learning from the ROSIS experience Where in the process are errors most likely to occur? Where in the process are errors detected?

30 Learning from the ROSIS experience Do certain situations give rise to more or more serious errors Stage in the process Technique Equipment Working environment

31 Just Culture - caution Introduction of a just disciplinary policy is not enough to bring about a just culture; the blame reflex is highly resilient Derek Ross, Psychology Department TCD

32 Just Culture - caution Requires an appreciation of the complexity of human behaviour and human error and how errors are managed

33 Just Culture - caution Once introduced the report form and reporting can become the focus The emphasis should be on the reasons for reporting To learn To reduce error potential

34 Reporting and Quality Improvement Reportanalysisfeedback Change of practice Review of effectiveness Raising awareness Safer practice


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