Event Investigations in a Just Culture

Assistant Vice President, Risk Management Group
AWAC Services Company, a member company of Allied World

Every psychiatrist and every member of the office practice strive to provide safe patient care.  But since we are humans and deal with humans, errors and adverse events may occur.  How the errors/adverse events are reported, investigated, analyzed, and how action plans resulting from the analysis are monitored to prevent recurrence is critical.  This article will focus on the importance of a just culture to improve patient safety in an outpatient psychiatry practice.

What is a Just Culture?

Traditionally, health care has had a punitive culture, holding individual practitioners accountable and disciplining them for any error or adverse event that a patient experienced under their care. Blaming an individual for an error generally does not change the error from reoccurring. It creates shame and often punishes the individual, which tends to result in the fear of reporting future errors. Yes, an individual can be at fault; however, chances are there is also fault in the system, which is designed by the organization or management team.

A Just Culture creates a non-punitive environment that empowers individuals to freely report incidents and actively participate in safety efforts.  Staff are more likely to report threats to patients’ safety when they trust that they and their colleagues will be treated fairly if they are involved in a patient safety incident. A Just Culture recognizes that individual practitioners cannot and should not be held accountable for system failures over which they have no control. A Just Culture is not a “free for all” where there is absence of accountability, but rather an environment where systems are investigated to see if they contributed to the error/adverse event and staff are held appropriately to account where there is evidence of gross negligence or deliberate reckless acts.

Why is a Just Culture Important?

A Just Culture is one where information about incidents or threats to patient safety are sought and addressed to make patient care safer and to achieve optimal outcomes for patients. Errors, near misses/close calls, and concerns about patient safety are flags of potential system weakness that may need to be addressed to improve safety.

A Just Culture promotes reporting incidents and errors to improve patient safety. Why? Because you can’t fix what you don’t know.

How Does Event Investigation Work in a Just Culture?

There are several steps with event investigation in a just culture:

  • Event reporting:  The primary purpose of a patient safety reporting system is to learn from the experience.  To do that, the incident/event is not seen as a failure but as an opportunity to improve and learn.  Delay any penalties (e.g., suspension/termination) while the incident is being investigated. Hold individuals accountable if a deliberate violation (reckless behavior) occurred; however, the goal is to build trust and encourage future reporting.

In building a reporting system, be mindful that although the individual report must contain important information about a specific incident or event (who, what, where, why and how?), “reporting system” refers to the processes and technology involved in the standardization, communication, analysis, feedback and dissemination of the lessons learned from the event reports. Ensure individuals in the practice understand their reporting obligations. Make it clear in the event report policy as to what should be reported and to whom the individual can speak about the event.

PLEASE NOTE: the event report is an administrative tool and not part of the patient’s clinical care. “Incident report completed” or a reference to the incident report, such as “See incident report” should not be documented in the patient’s medical record. The actual incident and patient care/interventions should be documented factually, objectively, and contemporaneously in the patient’s record, without blame of self or others.

  • Event investigation: Ideally, every organization/practice will respond to a serious event with an investigation. Include the individuals involved in the incident/event in the investigation to maintain morale, maximize learning, and reinforce the just culture.

If the investigation is done well, systems analysis of a serious adverse event can result in significant opportunities for improvement and risk mitigation. The additional benefit of these internal investigations is the opportunity for the practice to be prepared should an external investigation take place or potential claim be asserted.

Questions to consider during the investigation process would be what were the expectations, were procedures followed, were risks avoided, was the system/process design flawed, what behavioral choices were made?

  • Event analysis: This is the most important function of a reporting system because it leads to the opportunity for system changes. During this process, reports should be aggregated and analyzed to understand the frequency of the types of events as well as any patterns and trends. It is important to remember that individuals can only benefit from reporting events if they receive the constructive feedback gained from the analysis. The feedback should be easily understood and applicable to their setting.  Analyzing data in comparison to other organizations or benchmarks may also be helpful.
  • Monitoring and Auditing: In addition to feedback of the findings and analysis of reports, it is important to not lose sight of the corrective measures put in place as a result of the adverse event. Monitoring and auditing of process redesign is another way to evidence accountability within the practice. As part of a learning culture, it is helpful to review this process with a questioning attitude. Did the improvements work?  How are things going? Is the redesign sustainable? Are we capturing the system glitches?
  • Training: Provide basic education and training about Just Culture to everyone in the practice. Training will not only provide transparency about the practice culture but also serve to empower everyone in the practice to report events/incidents to improve safety by being part of the solution.

What Are Typical Behavioral Choices and Organizational Responses within a Just Culture?

There are generally three types of behavior associated with errors and adverse events in the healthcare. Included are also recommended practice responses to the behavioral choices within a Just Culture:

  1. Human Error: an unintentional failure in the way we think, for example, doing something other than what should have been done (i.e., a mistake or a slip).  An example of this would be a psychiatrist accidentally clicking on the wrong medication from the dropdown in the electronic health record. The response should be to console the individual who made the error and redesign systems to prevent future errors, such as requiring the reason with the medication choice.
  2. At Risk Behavior: occurs when the risk is not recognized or is mistakenly believed to be justifiable. The perceived benefits for taking the risk (e.g., saved time) are often immediate and positive, while possible adverse outcomes (e.g., patient harm) are often delayed and seen as remote possibility. An example of this would be a “workaround” by a psychiatrist ordering a controlled drug for a new patient without review of the state prescription drug monitoring program to save time. The response should be to coach the individual to help them see the risk associated with their behavioral choice that they had not seen or was misjudged as being insignificant or justifiable. Remedy the system failures and tacit rewards that are driving the behavior, such as improving ease of access to the prescription drug monitoring program [PDMP] or if allowed, delegate checking the PDMP to a staff member.
  3. Reckless Behavior: is a conscious disregard of a substantial and unjustifiable risk. Individuals who behave recklessly always know the substantial risk they are taking, do so intentionally, and are unable to justify the behavior. An example of this would be a psychiatrist diverting drugs for personal use. The response should be swift and appropriate remedial or disciplinary actions according to the practice’s human resources policies. The level of corrective action is determined by the practice’s disciplinary procedures and generally ranges from counseling or reprimand to more punitive actions such as termination of employment. System redesign to protect against future reckless behavior, such as averting drug diversion with robust system enhancement.

What are Examples of Event Reporting Opportunities within Outpatient Psychiatric Settings?

The following are types of incidents recommended for reporting in the outpatient psychiatric setting:

  • Medication errors (e.g., wrong medication or dose prescribed, contraindications for the use of medication resulting in complications of co-morbidity and/or problematic side effects to the patient)
  • Threats of violence and acts of harm (e.g., office property damage, verbal or physical assault towards others and harm to self/others)
  • Boundary issues (e.g., privacy violations, potential for physical or sexual assault)
  • Patient complaints and allegations (e.g., threats of reporting or actual notification to the Board of Medicine or the licensure board of another staff member, notice of a potential claim or threat of litigation from a patient or family member)
  • Breaches and violations of privacy (e.g., misdirected emails, release of information to the wrong patient/representative, use of unencrypted email, use of a non-compliant HIPAA EHR [Electronic Health Record] or telehealth platform resulting in a privacy breach)

How Do You Sustain a Just Culture?

Just Culture is more than words and policies. A Just Culture requires actions. The Agency for Healthcare Research and Quality (AHRQ) is tasked with improving the safety and quality of health care in the U.S. and stands behind the research of a Just Culture. The following are included among the recommendations they offer to ensure sustainability of this model:

  • Conduct monthly staff meetings and include patient safety as an agenda item
  • Implement transparent and biweekly (or even daily) “huddles” with staff to allow for easy reporting of safety concerns, especially if dealing with difficult patients
  • Allocate resources for safety needs identified by staff
  • Re-evaluate current disciplinary and corrective action policies and procedures
  • Empower all individuals within the practice, patients, and families to immediately intervene when they feel harm is likely

In Summary

Under the Just Culture model, creating an open-minded culture relies on setting expectations for individuals and the practice, accountability for behaviors around reporting and investigations of events to prevent error and promote safety. We know that humans make mistakes and “being human” is normal – no system is perfect! Given that premise, human error and adverse events should be considered outcomes to be measured and monitored with the goal being error reduction (rather than error concealment) and improved system design.1  The ultimate goal is patient safety and improving the systems to ensure that outcome.

Refer to your risk management consultant for additional resources on developing a Just Culture in your practice.

Leading for safety (American College of Health Executives) http://safety.ache.org/

Culture of safety organizational self-assessment (American College of Health Executives) http://safety.ache.org/quiz/culture-of-safety-organizational-self-assessment/

Leading a culture of safety: a blueprint for success (see self-assessment starting on page 33) (American College of Health Executives 2017) https://www.osha.gov/ shpguidelines/docs/Leading_a_Culture_of_Safety-A_Blueprint_for_Success.pdf

Medical office survey on patient safety culture (Agency for Healthcare Research and Quality 2019) https://www.ahrq.gov/sops/surveys/medical-office/index.html

The Differences Between Human Error, At-Risk Behavior, and Reckless Behavior Are Key to a Just Culture. Institute for Safe Medication Practices. June 17, 2020. www.ismp.org/resources/differences-between-human-error-risk-behavior-and-reckless-behavior-are-key-just-culture

Agency for Healthcare Research and Quality, Patient Safety Primer, Systems Approach, https://www.psnet.ahrq.gov/primer/systems-approach


About the Author

Tracey LeMay, BSN, CPHRM provides risk management consulting services to Allied World’s medical professional liability policyholders and insured psychiatrists, psychologists and psychiatric nurse practitioners and physician assistants. She works directly with policyholders to develop individualized action plans to mitigate potential loss based on their unique exposures and risk management needs. Additionally, Tracey assists these clients with ongoing medical educational programs as well as policy and procedure review and development.

1  Marx, D. (2001). Patient Safety and the “Just Culture”: A Primer for Health Care Executives.  New York,   NY: Columbia University