By Missy LeBlanc MD & Jake Luty MD
Healthcare systems are highly complex networks. They involve multiple interconnected systems that must function together to provide effective care, despite the constant risk for serious and even deadly accidents. Organizations that operate with high efficiency and safety despite these hazards are referred to as ‘High Reliability Organizations’ or HROs. Examples include aviation and nuclear power – both industries are incredibly complex and the stakes are high – mistakes in either setting can lead to catastrophic failures. Given the overlap in intricacy and consequence of errors, the concept of HROs has also been extended to healthcare systems.
In order for HROs to function at such a high level, they must strive for improvement through continual learning and the ability to adapt to an ever-changing environment. One way to achieve such adaptation is continued evaluation and improvement of your delivery system. This is done by adopting a ‘Just Culture’ that aims to balance individual- and system-based responsibility to allow for open reporting, investigation and education based on adverse events and near misses. Instead of responding to all errors with reflexive blame and retribution, it is assumed that even well-intentioned people will make mistakes and the focus shifts to preventing our systems from accommodating similar errors in the future. Such a culture helps us work as a team to improve both as individuals and as a system, maximizing the safety of the care we provide our patients.
OHSU and the Portland VA Medical Center, as healthcare systems striving to become HRO’s, work to create a ‘Just Culture’ by having open reporting of errors and near misses as well as having sites specifically related to the topic, so that we can continue to hone our skills and improve the ability of our systems to provide care safely. These reports are investigated by separate institution-based sub-committees, with resident representation on both sides of the bridge (at OHSU by our HQSC PSI sub-committee), who evaluate the cause of the event and put in place ways to prevent recurrence. Given the focus is on improving the safety of our system, errors of all types and degrees (even near-misses, where the error is caught before harm is done to the patient) should be reported. The road to becoming a HRO and establishing a robust “Just Culture” is long and difficult, but it is our duty to try, we can get there by working together, and there is no time like now!
Do you have a story that demonstrates Just Culture done well? Done poorly? Let us know in the comments section (ensure no PHI is used, this is a common forum) & stay tuned for a follow up post examining the ‘life-cycle’ of a Patient Safety Incident report.