Understanding why health-care professionals make errors, it is necessary to understand how poorly designed systems and other factors contribute to errors in the health-care system.
While errors are a fact of life, the consequences of errors on patient welfare and staff can be devastating.
When things go wrong the Just Cultue method of investigation looks at:
2️⃣ Policies, Proceedures
3️⃣ System Design
After this part of the investigation is complete, then the Just Culture method of investigation turns to the behaviour behind the error, and only blames and shames if the behaviour was reckless.