When we investigate Safety Net reports, we usually find one of three behaviors: (1) Human Error; (2) At-Risk Behavior; or (3) Intentionally Reckless Behavior.
In our weekly Just Culture quiz, 40 percent of those who responded to the recent example of a Human Error thought it was At-Risk or Intentionally Reckless Behavior. This means that 40 percent of us might have blamed or punished a colleague for a mistake. Sometimes it is hard to see the difference between a mistake and something risky or reckless.
Human Errors are mistakes, slips, lapses… things we didn’t do on purpose. For example:
... you accidentally order methimazole instead of metronidazole.
... you put supplies away while a colleague is telling you a funny story, and you put the Foley catheters in the wrong supply bin.
... you mistakenly put Patient A’s progress note into Patient B’s chart after a long and tiring shift.
A Just Culture does not punish people for making mistakes like these, no matter what the outcome. We know we are human; we are prone to certain kinds of errors such as substituting one thing for another or missing a step while being distracted.
Healthcare in general still has a fairly punitive culture where people are blamed for a human error – sometimes even at PPMC.