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[How we can learn better and more safely from serious incidents; translation of 'Just Culture' and 'Safety-II' into clinical practice].

Authors :
de Vos MS
den Dijker L
Hamming JF
Source :
Nederlands tijdschrift voor geneeskunde [Ned Tijdschr Geneeskd] 2017; Vol. 161, pp. D1090.
Publication Year :
2017

Abstract

After a serious incident, all involved expect it will provide an opportunity to learn and that improvements will follow. However, 'safe' learning is often threatened due to a primary focus on accountability. Focus should, instead, be on the needs of both patients and care providers, with the goal of repairing damage and restoring trust in the wider sense - a culture of justice ('Just Culture'). Common daily practice is a more realistic focus for further investigation, with active involvement of healthcare professionals ('Safety-II'). This means that an event is no longer reduced to 'human failure' but that complex work processes and interdependencies are thoroughly investigated, as to understand how things mostly go well but sometimes also go wrong. Deeper insight into the context of a serious incident and its relation to daily practice could ensure that plans for improvement are more closely aligned with this daily practice. Primary focus on the needs of those involved, and appreciation of the complex context, can allow for a safe and realistic approach to learning from undesirable events, such as serious incidents.

Details

Language :
Dutch; Flemish
ISSN :
1876-8784
Volume :
161
Database :
MEDLINE
Journal :
Nederlands tijdschrift voor geneeskunde
Publication Type :
Academic Journal
Accession number :
28294931