The way to improve safety and prevent Trauma is to learn about what causes of error and use this knowledge to design systems of care to “… make errors less common and less harmful when they do occur”. The obvious and cheapest way to do this is to make everyone in the Organisation responsible for the safety of the Organisation.
▶️ Humans make mistakes
▶️ Its impossible for anyone individual or Organisation to have a plan in place to avoid every risk
▶️ But Organisations and individuals can manage risks to lessen the impact of the adverse event when it happens.
When Organisations start by deciding what outcome they want to achieve and then work backwards to achieve that outcome. They are looking for someone to blame and shame.
The Just Culture asks all investigators to ask & answer these 5 questions:
▶️ Don’t assume you know What Happened? Ask and listen to the chain of events.
▶️ What should have happened according to the Organisational policies and proceedures.
▶️How did it happen if the Organisation is managing risk?
5 Skills necessary to create a Just Culture working environment
The Just Culture of looks at Organisational accountability from the perspective of the and measures the Organisation can take, including how the behaviours of the staff can be managed to improve Patient safety.
The behaviours are:
5 Rules to follow during a Complaint Investigation
This PDF provides a really good overview of the concepts involved in the Just/Accountable CultureJust-Culture-and-i-Sight-Investigations_1-2