The role of the Organisation in Just Culture Investigations.

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The way to improve safety is to learn about 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 types of errors and harm are classified according to where and when they happened.

The root causes of harm are identified in the following terms:

1️⃣ Latent failure—removed from the practitioner and involving decisions that affect the organizational policies, procedures, allocation of resources

2️⃣ Active failure—direct contact with the patient

3️⃣ Organizational system failure—indirect failures involving management, organizational culture, protocols/processes, transfer of knowledge, and external factors

4️⃣Technical failure—indirect failure of facilities or external resources