Comparing our industry to aviation, has been a discussion in almost all patient safety groups and initiatives. Recently the event of a Northwest plane that missed landing for about 150 miles as well as the incident with an Australian airline, where the pilots forgot to load the landing gear prior to landing and had to climb back up and re-attempt landing the plane, all these have made one thing clear, there are weaknesses to be addressed in both systems. No one of us is perfect, we are all a work in progress, yet we draw constant comparisons to each other.
The point of discussion here would be the action taken by management to these incidents. In both of the cases mentioned above, there are reports of the pilots being suspended awaiting an investigation. Again, a classic example of a "culture of blame".
Yesterday, I was most fortunate to attend a webinar by ASHP with speakers from ISMP and Outcome Engineering, among others. For those of you who don't know, David Marx from Outcome Engineering, is the pioneer and innovator of the Just Culture concept. It was truly quite an engaging and learning experience, which focused on three kinds of behaviors:
Human Error
At Risk Behavior and
Negligent Behavior (www.justculture.org)
The summary and conclusion of the webinar was really simple, first we need to look at the systems we work with, discover if there were any weaknesses or latent factors in the system that could have contributed to the error, and then we focus on the individual behavioral choices to determine if the individual made a conscious decision to disregard known policies and procedures. One of the questions I had asked and frequently ponder, is the comparison of this analogy to that of James Reason and his Decision Tree (www.bmj.com). In essence, the distinction between both is really that for the latter model, an adverse outcome has already occurred, whereas the Just Culture, takes into consideration all events, regardless of outcomes. In other words, even if the patient did not suffer any harm, the Just Culture model helps us determine the cause of actions as well as individual contribution to the error. It basically is a Fair and Transparent model.
One that we should all embrace, regardless of which industry we come from, or which model we follow, this type of model allows for continuous quality improvements and prevention of harm.
While I have no direct association with either Outcome Engineering, ASHP or ISMP, the fact that Captain Sullenberger was carrying the Just Culture book with him during that eventful day where he saved the lives of scores of people by landing his plane safely on the Hudson, should allow us a moment to consider what is being recommended by a national hero!
Till we meet again, Stay Safe!
The point of discussion here would be the action taken by management to these incidents. In both of the cases mentioned above, there are reports of the pilots being suspended awaiting an investigation. Again, a classic example of a "culture of blame".
Yesterday, I was most fortunate to attend a webinar by ASHP with speakers from ISMP and Outcome Engineering, among others. For those of you who don't know, David Marx from Outcome Engineering, is the pioneer and innovator of the Just Culture concept. It was truly quite an engaging and learning experience, which focused on three kinds of behaviors:
Human Error
At Risk Behavior and
Negligent Behavior (www.justculture.org)
The summary and conclusion of the webinar was really simple, first we need to look at the systems we work with, discover if there were any weaknesses or latent factors in the system that could have contributed to the error, and then we focus on the individual behavioral choices to determine if the individual made a conscious decision to disregard known policies and procedures. One of the questions I had asked and frequently ponder, is the comparison of this analogy to that of James Reason and his Decision Tree (www.bmj.com). In essence, the distinction between both is really that for the latter model, an adverse outcome has already occurred, whereas the Just Culture, takes into consideration all events, regardless of outcomes. In other words, even if the patient did not suffer any harm, the Just Culture model helps us determine the cause of actions as well as individual contribution to the error. It basically is a Fair and Transparent model.
One that we should all embrace, regardless of which industry we come from, or which model we follow, this type of model allows for continuous quality improvements and prevention of harm.
While I have no direct association with either Outcome Engineering, ASHP or ISMP, the fact that Captain Sullenberger was carrying the Just Culture book with him during that eventful day where he saved the lives of scores of people by landing his plane safely on the Hudson, should allow us a moment to consider what is being recommended by a national hero!
Till we meet again, Stay Safe!
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