1/2 - Just Culture

Question 1

What type of Failure?

Sharp End of the error

Unsafe Acts
committed by THE INDIVIDUAL in direct contact w/ patient or system

Slips / Lapses / Mistakes / Violations

Answer 1

ACTIVE FAILURES

Question 2

What type of Failure?

Blunt End of the error

Fundamental Vulnerabilities or conditions
of THE SYSTEM
that contribute to Active failures“Error provoking”

May have dormant stage where they are NOT leading to errors

Answer 2

LATENT FAILURE

Question 3

What type of Unsafe Act?

Behavioral choice that increases risk
where risk is not recognized, or is mistakenly believed to be justified

Ignoring Drug Interaction Alerts

Answer 3

At-Risk Behavior

• Failure to check 2 patient identifiers
• Failure to check allergies
• Use of verbal orders
• Omitting a time-out procedure before surgery
• Omitting a double check
• Sloppy handwriting on medical orders

Question 4

What type of UNSAFE ACT?

Behavioral choice to consciously disregard
a substantial and unjustifiable risk

• *Goals of behavior are self-centered** rather than
• patient-centered, organization-centered*

Answer 4

RECKLESSNESS

Reviewing a drug interaction alert…consciously recognizing it’s substantial risk…
deciding not to take action because your lunch break is near and you are very hungry.

Question 5

What type of UNSAFE ACT?

Slips / Mistakes / Lapses

Answer 5

HUMAN ERROR

Inadvertently doing something other than what should have been done

Question 6

How to manage a

AT-RISK BEHAVIOR?

Answer 6

COACH

Investigate and remove incentives for at-risk behavior

Create incentives for safe behaviors

•Increase mindfulness