Just Culture, communication to promote the safety of patients

67% of medical errors occurred because of communication problems.

This is shown by a study of the Joint Commission in which it is clearly demonstrated how transparency and communication are a challenge to be overcome, key in the safety of patients.

The existence of adverse events (AD) can have very negative consequences not only in the people who are treated, but also in health professionals. A punitive culture that encourages work environments that accuse, criticize, silence or stigmatize employees involved in EE can make the management of possible emotional, physical and professional suffering much more difficult.

 

What is Just Culture?

With the aim of creating a proactive patient safety culture that promotes fluid communication in hospital centers, The Patient Safety Company implements Just Culture. It is a system that offers employees the opportunity to openly express their views on the aspects of work that work and those that do not. Its goal is to encourage communication and error reporting to create a work environment in which everyone feels responsible for their actions and respects those of their colleagues, so that everything has a positive impact on patient safety.

The utilities of this system allow each employee to explain their professional experiences. However, this sometimes implies taking responsibility for decisions that have had adverse consequences, not only for the victims but also for those responsible and centers where these have occurred, known as second victims.

 

The punitive culture, a barrier

According to experts such as Sydney Dekker, a professor at Griffith University in Brisbane, professionals must know that error management will be fair and that the consequences will not be disproportionate. The fact that some professionals assume unfair or misplaced responsibilities makes their colleagues more difficult to communicate errors or to speak openly about their work and any doubts or concerns they may have about it.

A non-punitive culture includes the support of co-workers and superiors after an adverse event, avoids blaming workers for their mistakes and encourages the need to offer meaningful feedback. The actions that the Just Culture system applies can both prevent and mitigate the negative consequences of the EA.

In this sense, Just Culture contributes to balance responsibilities by learning from them, making compatible responsibility and learning. This culture involves dealing adequately with all situations, even those in which improper or negligent behavior has occurred.

 

A culture of just patient safety. Which requires?

According to Dekker, the necessary conditions to build a just culture are:

·       Do not assume that you can draw a line between desirable and undesirable behaviors.

·       Know how the institution manages incidents so as not to stigmatize employees. Make sure there is enough support and do not spread the blame.

·       Confirm that there is an independent division that manages errors and incidents.

·       Ensure that employees know their rights and obligations after an incident. Let them know what they can expect, with whom they can talk or not. In this way, transparency in the assumption of responsibilities can be guaranteed, a fact that will end up enriching, reinforcing and improving an organization.

The Dutch association VVAA, dedicated to offering financial services to health institutions, is also in favor of this culture. In addition, the entity insists that those who, unconsciously or unintentionally, make mistakes should not be punished. The key, he reiterates, is to stimulate communication about errors so that the entire organization can learn from them.

 

Medical Device Development 

Encouraging and promoting the necessary transparency and communication in the prevention, notification and management of incidents is, then, the main function of Just Culture. In the case of Spain, for this purpose, the Patient Safety Platform TPSC Cloud TM has been implemented since 2009. Its functionalities are based on the notification of errors and the analysis of causes, as well as the planning and monitoring of the improvement actions.

 

It is a tool used by more than 800 health organizations around the world including health networks, public and private hospitals, primary care centers, mental health centers, radiotherapy units, social health centers, blood banks, clinical laboratories, transplant organizations and IVF centers, among others.