Just Culture - PSOW 2015

To Err Is Human

Patient SafetyYour SafetyOur Safety

Culture of Safety

• 80% of medical errors are system‐derived• Good people simply working harder will not be sufficient to overcome the high complexity inherent in EMS.

• Errors will occur• The key is to design systems so that harm does not reach the patient.

Reason’s "Swiss Cheese" Model

Reason, James. Human error: models and management. British Medical Journal 2000; 320:768‐770.

Culture of Safety

• The benefit of this approach to managing behavior is that the process is up‐front and transparent to the staff, which helps to achieve trust.

• Risks become identified, reckless behavior isn’t tolerated, and ultimately the organization is safer.

• In practical terms, today you are 3x more likely to be involved in a MVC and 1,000x more likely to be involved in a medical error than in an aviation‐related incident, due in part to this cultural shift.

An Introduction to Just Culture

The single greatest impediment to error prevention in the medical industry is

“that we punish people for making mistakes”

Dr. Lucian LeapeProfessor, Harvard School of Public Health

Testimony before Congress on Health Care Quality Improvement

Safe Culture• The first and possibly most important step in promoting a safe

culture is the establishment of justice.– Just Culture – A system of shared accountability– The organization is responsible for safe system and process design– And employees are responsible for safe choices and behaviors

• This shifts an organization away from a “blame” culture. • Why? • Because to design safety, the organization needs feedback from

users (employees). • To give feedback, employees need trust. • An organization can establish this trust through a consistent and fair

approach to managing employee behaviors.

Establishment of a Just Culture

Establishment of a Just Culture• Outcome Engineering of Plato, Texas defines these three

behaviors as follows:• Human Error:

– An inadvertent action; inadvertently doing other that what should have been done; slip, lapse, mistake.

– Product of current system design and behavioral choices• At‐Risk Behavior:

– A behavioral choice that increases risk where risk is not recognized, or is mistakenly believed to be justified.

– A choice, risk believed insignificant or justified• Reckless Behavior:

– A behavioral choice to consciously disregard a substantial and unjustifiable risk.


• Human Error: – An inadvertent action; inadvertently doing other that what should have been done; slip, lapse, mistake.

– Product of current system design and behavioral choices

• Manage through changes in:– Processes & Procedures– Design– Training

• Console


• At‐Risk Behavior: – A behavioral choice that increases risk where risk is not recognized, or is mistakenly believed to be justified.

– A choice, risk believed insignificant or justified • Manage through:

– Removing incentives for at‐risk behaviors– Creating incentives for healthy behaviors– Increasing situational awareness

• Coach

Requires A Change in Culture

“Treat every drug administration as if it’s wrong and will kill the patient”

John Nance

• Suggested Meds:– Narcotics, to include Ketamine – Epi 1:1,000 vs Epi 1:10,000– Mag Sulfate– Any Pediatric Dose– Rarely used medications [Diltiazem]– All CCP medications


• Reckless Behavior: – A behavioral choice to consciously disregard a substantial and unjustifiable risk

• Manage through:– Remedial action– Punitive action

• Discipline

Accountability for Our BehaviorsHuman Error At‐Risk Behavior Reckless Behavior

Inadvertent action: slip, lapse, mistake

A choice: risk not recognized or believed justified

Conscious disregard of unreasonable risk

Manage through changes in:• Processes• Procedures• Training• Design• Environment

Manage through:• Remove incentives

for at‐risk behaviors

• Create incentives for healthy behaviors

• Increase situational awareness

Manage through:• Remedial action• Punitive action

Console Coach Discipline/Sanction

What do you see?

Just Culture – Not BlameAlso not carefree

• A just culture recognizes that individual practitioners should not be held accountable for system failings over which they have no control.

• A just culture also recognizes many errors represent predictable interactions between human operators and the systems in which they work; and recognizes that competent professionals make mistakes.

• Also acknowledges that even competent professionals will develop unhealthy norms (shortcuts, “routine rule violations”).

• A just culture has zero tolerance for reckless behavior.

Wrong Medication DoseHuman Error At‐Risk Behavior Reckless Behavior




“I drew up 4mg and gave it IV, then immediately realized that it should have been 0.4 mg”

“I would have double‐checked with my partner, but she was out getting supplies, and I wanted to get the patient treated”

“I have everything memorized and don’t rely on cheat sheets and can’t trust another medic”


















RSI: Paralysis Without SedationHuman Error At‐Risk Behavior Reckless Behavior




“3 am call, very busy night, I was tired”

“Patient had a head injury and was unconscious so didn’t need sedation”

“Patient is demented and won’t remember anyway” or “I’ve never had a patient complain”


















Accountability for Our BehaviorsHuman Error At‐Risk Behavior Reckless Behavior




Manage through changes in:• Processes• Procedures• Training• Design• Environment

Manage through:• Remove incentives

for at‐risk behaviors

• Create incentives for healthy behaviors

• Increase situational awareness

Manage through:• Remedial action• Punitive action


Assume Good Intent

Just Culture – Not Blame. Also not carefree. A just culture has zero tolerance for reckless behavior.

Just Culture - PSOW 2015

Health & Medicine