Just culture, reporting and learning cards

J1. Learning culture

To learn from safety occurrences and related issues, we need to look carefully at the trends, incident types, good practice, recommendations for improvement, and how these might apply to our work. When things go wrong, staff should not be punished for actions that are in keeping with their experience and training. Instead, understand what happened, support those involved and seek to improve work systems to reduce the risk of recurrence. People regularly adapt how they work out of necessity, however unacceptable behaviour must also be understood and dealt with.

J1-a Do you and your team incorporate lessons from trends, incidents, good practice and recommendations into your work?	J1-b How could you learn from events in your work?	J1-c A just culture is an organisational approach that balances accountability and fairness, viewing individual mistakes as an opportunity to improve systems rather than punish people? Do you talk about just culture? Is just culture the way you do things or is it viewed as just a policy?
J1-d If a colleague regularly took unacceptable risks, what would happen?	J1-e What is the best way for the organisation to deal with different types of unacceptable behaviour?

Reflection form

J2. Focus on the issue and avoid blame

Sometimes, we pay more attention to the person who raises a safety issue than the issue itself. Our perception of the ‘whistleblower’, ‘troublemaker’, or simply, responsible individual can affect our response.

If you arrive at the conclusion that something has gone wrong due to ‘human error’, this is a symptom of a deficiency in the care system or due to normal variability in the performance of people. Many safety incidents in health and social care cannot be attributed to ‘human error’ but involve a combination of interactions across the care system. In a healthy safety culture, we accept and manage this and commit to learn from it.

How people are treated when they report safety-related occurrences, including ‘normal system errors’ is a test for the just culture of an organisation.

J2-a When a safety issue is raised, do you focus on the message or messenger? How can we ensure that we focus on the message rather than the messenger?	J2-b How can we support leaders so that ‘normal errors’ are not identified as ‘causes’ during incident investigation and learning reviews?	J2-c When people report safety-related occurrences, are they blamed or treated in a just and fair manner?
J2-d How can we encourage a just culture within the organisation, department, care practice and the team?	J2-e Does the language used by the organisation support a just culture or a culture of blame?

Reflection form

J3. Safe reporting and confidentiality

We know that many safety incidents go unreported. The reporting of safety incidents is ultimately aimed at reducing reoccurrence and improving safety. Knowing how to report safety issues and incidents should be simple, but it is not always the case.

Timely feedback to people who raise safety issues is critical. It keeps them informed and helps maintain their motivation to continue to raise safety issues. Confidentiality is also important for safety reporting, investigations, learning and improvement.

J3-a How can we make sure incident reporting makes a visible difference and so motivates people to participate in reporting and learning to increase safety?	J3-b Do you know how to report situations that may compromise care safety and your own wellbeing?	J3-c How can incident reporting be simple and easy enough for everyone to understand and do?
J3-d Do people get timely feedback on the safety issues they raise?	J3-e What kind of feedback is best suited to the needs of those who raise safety issues, and when should this be given?	J3-f How confidential is the incident reporting and learning review system?
J3-g What level of confidentiality is needed, and how can this be maintained?	J3-h Is incident reporting sometimes abused or used inappropriately? How can we address this?

Reflection form

J4. Sharing the Learning

To learn from incidents, those who could find themselves in similar situations need to be aware of previous safety related events.

A good organisational and team-based safety learning review (e.g. mortality and morbidity meeting or learning from events meeting) should employ a systems approach to provide a meaningful account of what happened and the factors that contributed to it (e.g. task complexity, design of equipment, volume of work, time pressures, prevailing culture), and present workable actions for improvement to reduce the chance that it will happen again.

With open and fair discussion, lessons can be learned quickly after safety incidents to reduce the risk of recurrence.

J4-a Are reports of safety incidents readily available to you? How would you like to receive or have access to such reports?	J4-b How well do we review, analyse and learn from safety incidents at the organisation and team levels?
J4-c How do we talk about safety incidents?	J4-d How can we create the right environment for these discussions, so that we learn from experience?

Reflection form

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