2.5.2 Culture and patient safety incidents

Question 1

How can patient safety be improved?

Answer 1

By the reporting of concerns and learning from incidents. The reporting of concerns will only take place if individuals feel they will not be victimised and that it is ‘safe’ to report these concerns. To provide assurance and confidence, everybody needs to know where they stand.

Question 2

The airline industry has been embedding just culture principles into its practices for decades to improve safety. Adapting from what the airline industry has learnt, together with consideration of similar workstreams within the NHS, we believe in the following just culture principles for patient safety incidents:

Answer 2

1. Patient safety is paramount
2. Deliberate harm and unacceptable risk impacting on patient safety must not be tolerated
3. Patient safety is maintained by healthcare professionals being candid and raising concerns and learning from incidents to improve systems, standards, policies, legislation and people
4. To ensure that concerns will be raised and learning from incidents occurs, individual accountability must always be fair and proportionate, and viewed in the context of root cause, system deficiencies, mitigating circumstances and the entirety of contributing factors (i.e., the whole picture).

Question 3

See Diagram 5

Answer 3

Based on the NHS A Just Culture Guide.