Establish a Just Culture to Improve Patient Safety

From Safety I to Safety II

With the Institute of Medicine’s report, To Err Is Human: Building a Safer Health System, Centers for Medicare & Medicaid Services applied safety lessons gleaned from the aviation industry’s efforts to learn from defects. Under this new methodology, termed Safety I, human performance and errors are sorted into the following classifications:

• Skill-based — errors made due to inattention, considering one’s experience with an operation
• Rule-based — errors made from misinterpreting or deviating from standardized procedures
• Knowledge-based — errors made from lapses in judgement and decision-making

This framework is a helpful way to focus on the errors and how to eliminate them, but there are limitations. Emerging within the last 10 years as a response to those limitations is Safety II, an approach that focuses on the conditions that drive success.

By complementing Safety I protocols, Safety II more fully realizes the concept of a Just Culture.

Developing a Just Culture: Tools and Considerations

A Just Culture is a non-punitive approach that attempts to evaluate human behavior in an unbiased manner with respect to errors.

There are a variety of examples of Just Culture algorithms that you can use when developing a Just Culture at your hospital or health system, such as University of California, Irvine’s algorithm or University of Maryland Medical System’s tool.

With any Just Culture algorithm, the goal is to classify behavior into one of a few classes: human error, at-risk behavior and reckless behavior. The idea behind these classifications is that the systems and solutions put in place to mitigate or prevent the error will have to be tailored to the type of error. Very few medical errors are the result of reckless behavior that should require disciplinary action.

Before applying a Just Culture algorithm, ask yourself these questions:

• What happened?
• What normally happens?
• What, if any, procedures are applicable?
• Why did it happen?
• Are there any forcing functions that prevent errors like this?

There are also a few tests or thought experiments you can use to evaluate errors when they occur:

Substitution test — Would any equivalently trained employee have done the same thing? Would you have committed the same error?

Intentionality test — Was there a knowing violation of care standards?

Impairment test — Were any people involved impaired by substance abuse, withdrawal or other physical or mental health issues?

Using the tools and processes above will help your healthcare facility more effectively reduce medical errors by advancing a system of safety and self-improvement.