Establish a just culture to improve patient safety

Of security I to security II

With the report of the Institute of Medicine, for ERR is human: building a safer health system, the centers for the security services applied by the Medicare & Medicaid services drawn from the efforts of the aeronautical industry to learn defects. According to this new methodology, called security I, human performance and errors are sorted in the following classifications:

• Based on skills – errors committed due to inattention, considering his experience with an operation
• Based on rules – errors made from misinterpretation or deviating standardized procedures
• Knowledge – errors made from failures in judgment and decision -making

This framework is a useful way to focus on errors and how to eliminate them, but there are limits. Emerging in the past 10 years in response to these limitations is security II, an approach that focuses on the conditions that stimulate success.

By completing the security protocols I, Safety II fully fully achieves the concept of a just culture.

Develop a fair culture: tools and considerations

A fair culture is a non -punitive approach that tries to assess human behavior impartially with regard to errors.

There are a variety of examples of just cultivation algorithms that you can use when developing a just culture in your hospital or your health system, such as Irvine algorithm or the University of Maryland MEDICAL SYSTEM tool.

With any fair culture algorithm, the objective is to classify behavior in one of the few classes: human error, risk behavior and reckless behavior. The idea behind these classifications is that the systems and solutions put in place to mitigate or prevent error will have to be adapted to the type of error. Very few medical errors are the result of reckless behavior which should require disciplinary measures.

Before applying a right culture algorithm, ask yourself these questions:

• What happened?
• What is going on normally?
• What procedures are applicable, if applicable?
• Why did it happen?
• Are there forcing functions that prevent errors like this?

There are also some tests or experiences of thought that you can use to assess errors when they occur:

• Substitution test – would an equivalent employee do the same thing? Would you have made the same mistake?
• Was intentionality test-Is there a violation of health standards?
• Has depreciation test – have involved people were involved by drug addiction, withdrawal or other physical or mental health problems?

The use of tools and processes will help your health facility to reduce medical errors more effectively by advancing a safety and self-improvement system.

Implement a fair culture in your organization

Do you want to know more about creating a right culture in your hospital or your health system? Contact our practice development team. As a leading multi -purpose medical group, we use our clinical and operational expertise to build healthier communities.

This article was initially published on the Healthcare Invision website and was adapted for diving on health care. Original pauteur: Keenan Bora, MD, FAPEPE, Vice-president of safety and quality registers at Envision Healthcare.