Understanding Behaviors and Errors
Errors rarely occur as singular events. Typically, a sequence of events take place that contain multiple opportunities to prevent or correct am error as it moves through a system. When it comes to health care delivery and patient care, individuals can make multiple seemingly inconsequential errors that add up to something more significant. These errors come from conditions within the system in which the health care is delivered such as equipment failures, staffing issues, or structural system deficiencies. Clinicians must become strong error identifiers and reporters in order to improve system issues that may contribute to errors. If system problems go unreported, it can create a false sense of safety and efficiency to administrative leaders. In a just culture organization, clinicians routinely identify and report any unsafe conditions, system problems, or human errors because they are vested in a sense of trust that reporting such errors will lead to meaningful improvements and a safer organization.23, 46
When an organization transitions to a learning environment due to consistent reporting of errors and system problems it grows the trust employees feel in their organization rather than a sense of mistrust found in blame and shame cultures.
Organizational Learning from Errors and Near Misses
Organizations will often decide their reaction to an error based on the severity of the error and if harm occurred. Errors that do not result in harm are often times ignored and those resulting in harm are punished. In a just culture all types of error hold equal importance because they are seen as an opportunity for the organization to learn and avoid future errors. The reporting of errors is encouraged and a trusting and safe environment is created for the errors to be reported in. The reporting of errors provides opportunity for learning and system modifications that result in an environment where an organization is continually improving its processes and improving safety. Any event related to safety, especially those that involve human or system error should be viewed as a valuable opportunity to improve the system and safety of a health care organization. Ideally, health care organizations would use analysis of undesirable events to build an “organizational memory” of what happened. Understanding errors and near misses leads to an understanding of what events can occur and allows an organization to set systems into place to avoid them.46, 38
Types of Behaviors
The just culture model is based on three types of human behavior that can result in errors. “Human error is defined as an inadvertent action, slip, lapse, or mistake; at-risk behaviors are behavioral choices that increase risk where risk is not recognized or mistakenly believed to be justified; and reckless behavior is a behavioral choice to consciously disregard a substantial and unjustifiable risk”. 31
These three behaviors decide the potential outcome of the error incident analysis process. The at-risk behaviors are the most often cause for error because they relate to the human tendency to cut corners or drift. When drifts are repeated over time they become the norm and the standard of behavior. In a just culture, the responsibility for errors and patient safety is shared between the clinician and the organization. Clinicians should carefully examine their own at-risk behaviors or drifts and report them in order to provide the honest and accurate representation and data necessary to improve patient safety. The outcomes of error reporting must be fair and just for the employee to feel trust in the process. If the outcomes of error reporting are not fair and just it is unlikely that an individual will fully report errors which can create a secretive and dishonest environment in which errors are hidden from the organization.42, 3, 34
Human error, inadvertent mistake, slip or lapse (Just Culture: human error)
Product of Our Current System Design and Behavioral Choices
Manage through changes in:
minimization of or failure to recognize risk resulting in deviation from process, policy or system (Just Culture: risky behavior)
A Choice: Risk Believed Insignificant or Justified
- Removing incentives for at-risk behaviors
- Creating incentives for healthy behaviors
- Increasing situational awareness
Intentional violation of process, policy or system.
Conscious Disregard of Substantial and Unjustifiable Risk
- Remedial action
- Punitive action
Retaliation for Errors
The Agency for Healthcare Research and Quality: 2016 User Comparative Database Report compiled data from 680 U.S. hospitals and found that one of the top three areas for potential improvement in health care is a non-punitive response to error. The survey resulted from 447,584 staff members from 680 hospitals and found that hospital staff believe that their mistakes are held against them (49%), that they are being reported on instead of the problem (52%), and that their errors are kept in their personnel file (63%). The culture described by the hospital staff is one in which error reporting would be unlikely and therefore patient safety would suffer. It is time in this country for a systemic shift in health care to a just culture model.34, 11
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