Just Culture in the world of EMS and how it can change the way you react to an incident.
By: Matt Reinhart EMT-P, FP-C Cortex Navigator Ninth Brain Suite
The pager of an administrator of a fairly large EMS agency goes off early in the morning alerting him/her that an incident has happened with a patient being dropped from a cot. The administrator calls into dispatch and hears that it happened at the receiving ER and the patient appears to have been injured from the fall. He/She also remembers sending this same crew on a 6-hour transfer of a very critical patient just before going to bed. The crew was just arriving back within their service area when a 911 call came in and they were only a few blocks away. After investigating further, the crew had to park outside the normal ER garage due to the barrage of calls happening during the night, forcing the crew to wheel the patient up the walkway to the ER in a dim light ER entrance. The wheel caught a corner and with having the monitor and med bag on their shoulders, they couldn’t catch the cot before it fell. After reading this scenario, what would your response be to the crew? Is it easy to react to a patient that was just dropped and think how fast you can pull the crew members responsible for this out of your agency? Is it easy to react to the severity of the situation vs. fully evaluating the situation leading to the incident? This very same situation happens all too often in the EMS industry.
The term Just Culture is a fairly new term not only just in EMS but really in all industries. It was first only reported in the early 2000’s. The Just Culture model not only promotes administrators to fully look at incidents but also promotes reporting to give opportunity to prevent incidents from happening. Use the scenario at the beginning. If this crew is immediately fired and word spreads, what other situations would be impacted? Would a different crew that was placed into the same situation feel that they can comfortably report fatigue? Would the company look at its policies revolving long distance transfers and handling how crews return into the rotation? Probably not, due to the reactive nature in the response. Now Just Culture doesn’t promote employees that disregard polices and act without due regard to the risk involved be given multiple chances; but asks administrators to take this opportunity to take a step back and look at the steps proceeding to the incident and see how it could have been avoided. This process helps to handle the employee(s) involved.
I have another scenario that I was personally an administrator for. A flight nurse sets her jacket down on the seat on the side of the aircraft. She then proceeds to perform a walk-a-round of the aircraft. After getting back to the door, the pilot begins starting the aircraft and the nurse grabs her jacket and steps into the aircraft. After landing at the referring facility, the nurse opens the door and sees her stethoscope wrapped around the skid of the aircraft. She recalled that she placed it on the seat and it must have been pulled out from under her jacket when she grabbed her jacket after performing the walk-a round. The incident was then reported through our near miss safety reporting. This could have been obviously a different outcome if the stethoscope did not stay secured on the skid during the 10-mile flight. The crew could have avoided reporting and not been subject to obvious scrutiny, but they did report it, and were recognized for telling their story. I can promise you that multiple crew members looked at the skids prior to jumping into the aircraft due to their story bringing new awareness to what could happen. If a Just Culture model is not implemented into an organization, near miss reporting would not be encouraged and the ability for you as an administrator to evaluate risk is diminished.
The Just Culture algorithm is available for you to evaluate incidents through multiple different resources. It will help you walk through the incident and investigate the precursors of why it happened, so you can best handle the employee involved. The algorithm will point you to if the employee(s) were using At Risk behavior, Human Error, or Reckless behavior. Using this model will not only help you evaluate risk in your program, but help you maintain an efficient working staff.
Some of the best and most popular educational sessions in medicine are case reviews. They present a case that some organization experienced or critical patient that is a high risk/low volume type situation. The case is evaluated and what we should have done and what worked is looked at with scrutiny and success. The question that the Just Culture model presents is “Are you performing case reviews at your organization?” Use the Just Culture model to guide and promote reporting to provide a safe and happy workplace!
