Objective
To extend the principles of Just Culture across healthcare facilities (primary care, hospitals, and social-health care centers) by incorporating a tool in the form of an algorithm or decision tree. This tool is designed to support the root-cause analysis of safety incidents, guiding reflection on professional performance while balances human factor (fallibility) and system failures or conditions, with the ultimate goal of learning from what happened and strengthening clinical safety.
What are we looking for with this tool?
Structured support for safety incident analysis.
To provide teams responsible for root-cause analysis with a systematic and consistent framework to classify professional performance in the occurrence of a safety incident from a Just Culture approach.
Differentiation of types of professional performance.
To help differentiate, explicitly and consistently, between:
- honest mistake
- acceptable risky behavior (justified exception)
- undesirable risky behavior, and
- reckless or imprudent behavior,
avoiding punitive interpretations and encouraging proportional and well-founded decisions.
Consideration of human and system factors.
To promote a shared understanding of human fallibility in clinical decision-making, placing individual performance within the context of existing organizational, technical, and healthcare conditions.
Cross-cutting applicability.
To provide an operational and adaptable tool for different healthcare environments and the professional profiles involved in healthcare delivery.
Effective implementation of Just Culture.
To identify barriers and facilitators for incorporating Just Culture principles into routine safety incident analysis and management processes.
What do we expect?
That working groups and safety committees responsible for the root-cause analysis of incidents affecting patients incorporate this tool into their routine workflow, fostering a coherent and explicit application of Just Culture principles. In particular, it is expected to facilitate the balance between individual accountability and the systemic factors contributing to the origin of incidents, guiding the analysis toward organizational learning and the continuous improvement of clinical safety.
