Importance of Just Culture
Medical errors and medical errors leading to deaths are largely underreported in this country creating a dynamic where errors that could be prevented through systems changes are not. Just culture must be implemented across health care organizations to improve the reporting of errors and improve safety within the health care system. Where so much in health and medicine is out of our control, implementing a just culture is something we can do to save lives.
The majority of errors are not caused by bad clinicians; the majority of errors are caused by poor systems. The current organizational responses to errors such as scrutinizing the individuals involved, establishing committees, and changing policies, are not enough. We must address human behavioral factors and system issues to prevent future errors.
We must address human behavioral factors and system issues to prevent future errors.
Human factors that can contribute to errors are fatigue, stress, communication failures, fear of speaking up, and a blame, shame, and retribution culture. They all contribute to reductions in error reporting and poor patient outcomes. A just culture of fairness and safety entails support from the highest levels of a health care organization for error reporting and resource allocation that promotes risk reduction and error reduction and supports system improvements. Studies show a strong correlation between a health care organization’s lack of culture of learning and safety and lack of risk behavior reporting. A culture of safety that fosters transparency, trust, and open communication is imperative to an organization’s ability to deliver highly reliable, safe, quality care.49, 39, 5, 42
Medical Errors are Inevitable
Medical errors happen. People make mistakes. Those two factors are unchangeable. What is within an organization’s control however is how they respond to errors and whether they utilize them as a learning experience that reduces future errors or if they use them to point the finger at an individual with blame and shame.
Medical errors are the third leading cause of death in the United States, with an estimated 44-98,000 Americans die each year due to medical errors. Health care is at least a decade behind other high-risk industries such as the airline industry in creating cultures of safety in their organizations. Creating a culture that encourages individuals to report errors, and organization to evaluate the causes of those errors, and to make appropriate changes to the systems in place that have led to errors is essential to a comprehensive strategy to improve patient safety and outcomes in the medical filed. While there have definitive steps towards improvements in the health care industry, there is still much to be done and a grave public health concern. A strong criticism of current event reporting databases is that they only capture a very small percentage of the actual amount of adverse events. Error reporting can be a fundamental mechanism to learning in health care organizations as long as the reporting leads to ways to identify and mitigate system failures or areas for system improvements.25, 40, 49, 28, 39, 35
Borrowing from Other Industries
Health care has taken many of its safety practices from the field of aviation and how they manage events and mechanisms they utilize to report errors and near misses including the Aviation Safety Reporting System. Data on errors plays a vital role in health care organization’s ability to improve patient safety.47, 32
Complexity of Care & Technological Landscape
Errors and adverse events occur in health care for a variety of reasons including the complexity of care provided, environmental factors, failures in communication, and failures of interaction between humans and technology. Within health care organizations it is essential to have a clearly communicated culture of fair and learning just culture. Health is the largest employer of individuals in this country and every individual is imperfect. Even the best systems are designed by imperfect individuals and require constant scrutiny for areas of growth and improvement. Every introduction of new health care technology brings with it the potential for unanticipated errors. Improving patient safety and outcomes requires much more than relying on well-designed systems and technology. Improving patient safety and outcomes requires an organizational commitment to trust, fairness, and a just culture of reporting and safety.48, 46
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