This article originally appeared in the November newsletter of the National EMS Management Association and is republished here with permission.
By Brian Behn, B.A., NR-P, FP-C
Just Culture takes a balanced approach between a blameless culture and a punitive culture. A blameless culture has no accountability, shoulders are shrugged, people mention “bad things happen to good people,” and move on. The opposite of this is a punitive culture in which honest and unintentional mistakes are punished.
A common misconception about Just Culture is that a blameless society is encouraged; one where providers “get off the hook” for making mistakes. This is not the case. Rather, Just Culture asks why providers should be on the hook in the first place. Just Culture recognizes that human nature is inherently fallible and errors are endemic in any field that relies on human performance. Encouraging the attitude of asking what is to blame instead of who is to blame is at the heart of Just Culture.
A culture of learning and shared accountability
In an agency with a healthy quality improvement program, all providers are stake holders. Providers feel free to discuss any safety concerns they have, and self-reporting of both errors and near-misses happens on a regular basis. Providers feel free to share the lessons they have learned without fear of punitive repercussions or being perceived as incompetent by the quality officer and, more importantly, by coworkers.
Medical errors can be overwhelming and an extremely uncomfortable experience for a care provider. After an error is made, providers may experience intense feelings of:
- Guilt.
- Humiliation.
- Worthlessness.
- Questions about job security.
- Fear about legal ramifications of the incident.
- Wondering if they will be labeled as incompetent by their peers.
If these feelings are not addressed, they may lead to the provider acquiring what is known as second victim syndrome.
The practice of issuing disciplinary write ups, sanctions, suspensions or terminations for honest mistakes, slips and lapses is referred to as a punitive QA model.
Practicing punitive QI is a cardinal sign of an “unhealthy” program. In the “healthy” EMS QI program, the QI officer acts as a resource to staff, engages in coaching, educates or fills the role of an EMS consigliere of sorts. Unfortunately, many QI programs are not healthy. Unhealthy programs seek to assign blame to providers for errors and engage in punishing providers who make mistakes. The use of punitive and other unhealthy practices in QI paradoxically results in a less safe system.
When faced with punitive action at work, providers may be reluctant to share information about mistakes they or others have made, regardless of the health of the QI system. When the EMS agency has a punitive system in place, providers become even more reluctant to report on errors and near misses and may attempt to conceal them.
In the year 2000, Dr. Lucian Leape testified before congress about medical errors in America. “There is a social ostracism in healthcare often and that has been the single major barrier to improvement. Because we treat errors as sins, because we treat people who make errors as bad people, they hide and they conceal.” Seventeen years later, one could argue that we are still fighting the same battle in healthcare.
When a medical error occurs, it is important to understand why it happened. But be forewarned; getting to the actual root cause (or more likely, causes) is as much an art as it is a science. In most medical errors, a system component is usually to blame for the issue. This could be:
- Lack of training.
- Lack of cognitive coaching.
- Unclear protocols.
- Poorly designed equipment.
Resolving system errors is the most efficient way of preventing the same error from happening to another provider.
Should an investigation conclude an EMS provider is one of the causes behind the incident, classifying the behavior into one of three Just Culture behavior categories will provide a launching point for figuring out what comes next. It is important to note these behaviors do not exist in a vacuum. Human behavior is only one piece of a larger picture in understanding the conditions that make it possible for an error to exist. These are the three behaviors:
1. A simple mistake
The key to determining if a medical error is a simple mistake is the action of making a choice. A simple mistake does not involve choices being made by an employee; it is usually an unconscious error that is only discovered in retrospect. This is also known as a slip, lapse or absent-minded error. When asked about the event, the employee often expresses the sentiment of, “I don’t really know why I did it.”
The term “simple” should not be a distractor or viewed as downplaying the outcomes or harms, but simply refers to the actions that caused the event.
When an employee makes a simple mistake, the actions taken by the QI department should be non-punitive. One of the first things that must occur is consoling the employee who made the mistake. As mentioned above, making a medical error can be an emotionally difficult experience; it can be overwhelming and extremely uncomfortable.
How the QI department proceeds with regards to employees who make errors can have an enormous impact on the employee and the agency. The provider who made the mistake needs to be made aware the agency is there to support him or her. Providers need to feel safe in order to feel comfortable sharing the lessons they learned from the incident. Follow up should include looking for ways to share what happened with others to prevent future recurrence of the issue. This could be as simple as sending out an email or it may entail policy and procedure reforms.
2. At-risk behavior
Unlike a simple error, where the provider did not make any choices or decisions, at-risk behavior is defined as making a choice involving unrecognized risk or justifying an unsafe choice. A provider has no intent to cause harm or to be unsafe with at-risk behaviors; the risks are simply miscalculated, overlooked, or the provider does not properly weight the risk versus the benefit of the action.
Human nature sometimes results in bending the rules or omitting steps that seem unimportant when completing a task. Unfortunately, these steps usually exist to act as a safety net. Examples of at-risk behavior might include not checking the name bracelet on a patient or failing to obtain a set of vital signs before administering a dose of nitroglycerin to a patient with chest pain.
The classic example of at-risk behavior is exceeding the speed limit. When people speed, they often have a reason, and in the heat of the moment, the advantages of speeding outweigh the perceived risk of speeding (e.g., a ticket, getting in to an accident, etc.).
When at-risk behavior is determined to be one of the causes of the error, the provider should be coached on making safer choices in the future and they should explore what led them to choosing the unsafe action to begin with. Corrective action could include examining the cognitive bias at play, drift from procedures and policies, shortcuts or the source of improper knowledge. It is important to emphasize that retraining, re-education and remediation are not punitive practices, and the goal is to make a safer organization for both patients and providers.
3. Reckless behavior
Reckless behavior involves making conscious choices that disregard safety for patients, coworkers and communities. Arriving at a decision of reckless behavior by the QI officer should not be taken lightly and should only occur after a very thorough investigation.
At the heart of reckless behavior is an unjustifiable reason for breaking the rules or placing others in harm’s way. The line between at-risk and reckless behavior may initially appear to be blurry and hard to define. Getting to the root cause of why the error occurred is crucial in assigning one of the three behaviors to the incident. Examples of reckless behavior include practicing punitive medicine towards patients, arriving at work while intoxicated, and selling drugs from an ambulance. Investigations resulting in a finding of reckless behavior should be referred for disciplinary action according to company policy. Reckless behaviors cannot be tolerated in our agencies and are the only appropriate example of using punitive action in a quality program.
The astute reader will notice that there is no mention of the outcome or severity of the mistakes mentioned in this article. A QI program that embraces a “no harm, no foul” approach to medical errors is relying on luck as a measurement. Viewing the incident from the position of hindsight (or an outcome bias) is a double-edged sword. An outcome with no harm resulting can bias the viewer as much as an outcome where death or severe harm occurred.
In the investigation the Clapham Railway Junction crash, Anthony Hidden QC stated the following, “There is almost no human action or decision that cannot be made to look more flawed and less sensible in the misleading light of hindsight. It is essential that the critic should keep himself constantly aware of that fact.” This is sage advice for any person that is tasked with doing QI duties.
Just Culture is not an overnight transition
Simply purchasing an algorithm or attending a few hours of training (or reading an article such as this) is not enough for an agency to be able to say they practice Just Culture. Stating a practice of Just Culture is easy; actually performing Just Culture is much, much harder. Establishing Just Culture in your agency requires real change, a shift in beliefs by the entire agency, administrative staff, and all providers. All members of the agency must embrace the notion that even the best providers can make mistakes when providing healthcare.
Just Culture takes time and practice, and is not an overnight transition. Assigning one of the three behaviors serves as a starting point, not an end point, for understanding what went on in your agency and, more importantly, how to change and grow from it.
References
- Dr. Leape testimony during -MEDICAL MISTAKES: Joint hearings before the subcommittee on labor, health and human services, and education, and related agencies committee on appropriations the committee on health, education, labor, and pensions and the committee on veterans’ affairs United States senate one hundred sixth congress first and second sessions special hearings. Available at: https://www.gpo.gov/fdsys/pkg/CHRG-106shrg61732/pdf/CHRG-106shrg61732.pdf
- Wu AW. Medical error: the second victim. The doctor who makes the mistake needs help too. BMJ. 2000;320:726-727
- Grissinger M. Too Many Abandon the “Second Victims” Of Medical Errors. Pharmacy and Therapeutics. 2014;39(9):591-592.
- “Why punishing medical mistakes won’t make patients safer” http://www.kevinmd.com/blog/2012/09/punishing-medical-mistakes-patients-safer.html
- When primum non nocere fails. Lancet. 2000;355(9220):2007.
- Goldman, B. “Doctors make mistakes. Can we talk about that?” Available at: https://www.ted.com/talks/brian_goldman_doctors_make_mistakes_can_we_talk_about_that#t-1068189
- Scott, S. The Second Victim Phenomenon: A Harsh Reality of Health Care Professions. Available at: https://psnet.ahrq.gov/perspectives/perspective/102
- McCartney Margaret. Margaret McCartney: Punishing individuals won’t prevent errors BMJ 2017; 356 :j1279
About the author
Brian Behn is a paramedic and quality assurance officer for Chaffee County EMS and a member of the NEMSMA Quality Improvement Committee. He can be reached at behnbrian@yahoo.com.
