Human fallibility is an inseparable part of any work environment. No matter how skilled, experienced, or how much a workforce is well trained, errors will always occur. In health and safety work environments, such errors have potentially disastrous consequences, including injuries and death. Hence, it is essential for organisations to not only recognise but also understand the importance of human error in the operations of such organisations. They should also adopt a Just Culture that aims to foster a transparent and open culture. A just culture is an approach that entails learning from errors and correcting systemic shortcomings rather than punishing and blaming people for their mistakes. This approach understands that human beings have limitations, and mistakes are usually due to systemic flaws as opposed to individuals’ negligence. With a culture of transparency and responsibility, companies will be able to identify the risks and take corrective action, leading to a safer workplace. This essay discusses the nature of human fallibility within a workplace risk situation and how the ideas of a Just culture can be used to develop a workplace culture that values transparency and accountability in the health and social care industry.
Human Failure and Its Types
Human failure, or human fallibility, refers to the ability of a particular person to err in their surroundings. All these errors can be caused by many factors, such as tiredness, inattention, or a lack of adequate training, and they pose significant risks in terms of safety and health. The major types of human failure are human error and violation (Bindra, Sameera and Rath, 2021). Human error is accidental, and examples include slips, lapses, and even mistakes. A slip occurs when an individual intends to do something, but by mistake, a different action is done; for instance, a nurse who plans to administer medication through the oral route but instead administers the dose via the wrong route. A lapse is a momentary inability to recall or pay attention, such as forgetting to note a patient’s vital signs. Errors happen when the intention of a person is wrong and they do not get the desired result. For instance, when a nurse inadvertently administers the wrong dosage of the medicine to a patient.
On the contrary, violation is a conscious action that is contrary to the set rules or procedures. These can also be classified into three types, namely situational, routine, and exceptional violations. Situational violations are those that deviate from the norm due to unforeseen circumstances, such as giving a drug at an alternative time due to an emergency medical condition. A violation that becomes the routine of the individual, is usually the result of outside forces like failing to observe a safety protocol to save time. Exemplary violations occurs when a person feels the desire to get to the other side of the law, although they are well aware of the fact that they will be punished. For instance, a nurse may ignore a medication administration protocol to please a patient who demands attention. In the work environment, such forms of human failure can result in severe outcomes, from minor missteps to major incidents or accidents. In a risk event where a nurse mistakenly administers a medication, the results may be lethal for the patient and would have legal, financial, and reputational consequences for the institution.
Situation of Risk in The Workplace
In a hospital environment, a risk situation can arise in the operating room when a surgical procedure is being performed. For instance, one of the most prestigious hospitals in the country failed to observe proper safety protocols. Hence, a surgical instrument was left inside the patient’s body, causing infection and severe damage. This event may have arisen from poor communication, inadequate staff training, poor supervision, or other general system failures. Such an event may cause serious harm, not only to the patient himself but also to the hospital’s reputation and its stability as a financial institution. This is especially important in hospitals, where a Just Culture should be put in place to prevent such incidents and foster an open communication channel and an environment that focuses on continuous improvement for the safety of all stakeholders.
The Consequences of Human Failure
In a hospital environment, where human life is at stake, human error can be disastrous. It is therefore necessary to discuss two approaches: the system approach and the person approach when analysing the implications of human error. Elements of the systems approach relate to the system failure and organisational aspects resulting from human error, whereas the person approach emphasises individual accountability for one’s actions. Operative active failures, which would be correlated if a surgeon makes a mistake during an operation, are usually related to inherent system failures as well as poor communication or lack of training. However, other latent failures resulting from inferior machinery or misleading protocols can cause human error in a hospital setting. The latent failures are the passive failures that are dormant until the active failures in the form of incidents and accidents are triggered. It is, therefore essential that the hospitals have a Just Culture, concentrate on systems and human factors to reduce errors, and have a safe nursing practice.
The Swiss Cheese Model
The Swiss Cheese tool is a powerful tool for analysing errors in human behaviours in any hospital environment. It depicts the various defence layers that are supposed to ensure that accidents or incidents do not take place. Nevertheless, like a piece of Swiss cheese, these layers could have holes or weaknesses that can break down, resulting in an error or accident. In a hospital environment, the model allows the organisation to focus on the active failures, such as the nurse administering the wrong drug, and the latent failures, such as inadequate training or the absence of double-checking procedures, that led to the mistake (Sameera, Bindra, and Rath, 2021). By knowing these factors, the hospital can take preventive measures so that such errors do not recur in the future.
Conclusion and Recommendations
Overall, every workplace has its fair share of human mistakes, and the effects of such mistakes can cause severe damage to people and institutions. It is, therefore, important for organisations to understand and cope with human failure through a systems and person approach. Through proper training and protocols and the use of tools such as the Swiss Cheese model, organisations can prevent errors, promote safety, and achieve better performance in general. Further, organisations must take the initiative of implementing training and refresher courses on the safety procedures and protocols to manage human fallibility effectively. Organisations should also ensure that they have enough workers to prevent the human errors that may follow when an employee is overworked and very tired. Finally, the continual evaluation and refinement of the existing systems and procedures can help to detect any defects that could lead to many errors.
Consequently, organisations should implement a Just Culture to deal with human fallibility and mitigate the chances of errors. This is a culture in which errors and near-misses can and are reported without fear of charges or reprisals. Under a Just Culture, there is no punishment for mistakes but on learning process and discovering the underlying systemic problems that caused the first mistake to occur and how to prevent their re-occurrence. Additionally, in a Just Culture, people are not blamed for their mistakes but the errors are identified and corrected. With this approach, others are encouraged to report mistakes to avoid such errors repeatedly.
Just Culture in The Context of Managing Human Fallibility
Just Culture is a managerial philosophy that entails promoting a culture of truthfulness and learning within the workplace instead of punishing and blaming employees for their mistakes. Emphasising human fallibilities, a just culture takes people who are naturally imperfect and therefore fallible and, therefore, are prone to errors for which systemic issues that cause errors must be identified and investigated. It does away with punishment, thereby encouraging people to report errors and near misses without any punishment, hence allowing organisations to identify potential risks that would help them to improve their systems (Paradiso and Sweeney, 2019). The Culture around the organisation also works to create a Just Culture that helps and equips individuals with the needs and training required to prevent other such mistakes. With this approach, organisations can effectively manage human error and create a culture of accountability and continuous enhancement.
Importance and Benefits of Adapting a Just Culture in Organisations
The concept of a Just Culture is fundamental in the development of a fair and accountable work environment. This approach argues for fairness with regard to treating employees and empowering them to take their own decisions or precautions, without fear of any punishment. In this way, the Just Culture helps organisations spearhead open communication and feedback, which makes the openness more insightful and helps them learn from mistakes (van Baarle et al., 2022). As a result, this creates a good work environment that motivates employees to raise the employees’ morals and satisfaction. In addition, a Just Culture promotes a preventative approach to risk management and encourages employees to disclose errors and near-accidents without any punishment. By identifying and correcting systems for design fallacies and human fallibility, organisations can improve their processes as well as the overall safety levels. Besides, processes for implementing a Just Culture also create ideal environments for better decisions and problem-solving from employees leading to increased performance and business success.
Approaches to Just Culture
There are two broad Just Culture approaches, the retributive and the restorative justice principles. The concept of retributive justice is punishment-oriented and blames individuals who cause an incident or mistake (Heraghty, Rae and Dekker, 2020). This method is quite common in the traditional health set-up where human errors are considered the only factors to consider in problem-solving. In such a culture, people may be reluctant to report mistakes owing to fear of punishment which makes the mistakes go undetected hence, the identification of systemic issues and other problems becomes difficult. In contrast, restorative justice seeks to understand what caused an incident and to learn from it to prevent similar situations in the future (Pavlacic, Kellum and Schulenberg, 2021). Its goal is to guide, if possible, the individuals involved in an incident, rather than blame them. This practice reinforces an environment of accountability and fosters open communication that creates an avenue for unearthing underlying problems and instituting a system-wide change.
Considering the above risk situation, restorative is a better approach because, in its use, underlying problems that led to the surgical instrument being left in the body of the patient are assessed comprehensively. By maintaining open communication and using a focus on continuous improvement to identify and address systemic issues like inadequate training, poor supervision and reporting lines of communication in the operating room, hospitals can resolve these issues. This strategy not only stops future occurrences but also fosters among them a work culture based on trust and responsibility. Additionally, it adheres to the rules of a Just Culture, in which the aim is to make safety better for all stakeholders, not just penalising the individual.
Conclusion and Recommendations
Conclusion
Human error is an inherent and irrepressible trait of any work setting. For optimal risk management, organisations must ensure the implementation of a Just Culture which strives for transparency, accountability and permanent improvement. This method of improvement from human error recognises that human errors are caused by systemic failures and is focused more on causes and less on people. A Just Culture will allow organisations to create a comfortable working environment as well as raise the level of quality in processes and working environments. Moreover, an open and supportive culture encourages open communication in a Just Culture which elevates employee attitude as well as their sense of satisfaction. Furthermore, two forms of Just Culture exist, retributive and restorative justice; the latter proves to be a more effective general outline for dealing with the human error factor. Utilising restorative approaches, organisations can prevent future incidents and also engender an atmosphere of trust, accountability and learning. This is indeed important for any health and social care sector organisations to realise that they have to introduce a Just Culture to curb the risks of having the impacts of disasters.
Recommendations
To provide a safe working environment and promote Just Culture, organisations should get leadership commitment, streamline learning and training systems and build a culture with continuous learning and improvement. Reviewing and, if necessary, changing the policies and practices should be done regularly to identify vulnerable spots that could result in errors. Organisations that would embrace these recommendations would successfully manage human fallibilities and create a setting that supports oneness, accountability, and safety for all the stakeholders.
References List
Bindra, A., Sameera, V. and Rath, G. (2021). Human errors and their prevention in healthcare. Journal of Anaesthesiology Clinical Pharmacology, [online] 37(3), p.328. doi:https://doi.org/10.4103/joacp.joacp_364_19.
Heraghty, D., Rae, A.J. and Dekker, S.W.A. (2020). Managing accidents using retributive justice mechanisms: When the just culture policy gets done to you. Safety Science, [online] 126, p.104677. doi:https://doi.org/10.1016/j.ssci.2020.104677.
Paradiso, L. and Sweeney, N. (2019). Just Culture: It’s more than policy. Nursing Management, [online] 50(6), pp.38–45. doi:https://doi.org/10.1097/01.numa.0000558482.07815.ae.
Pavlacic, J.M., Kellum, K.K. and Schulenberg, S.E. (2021). Advocating for the Use of Restorative Justice Practices: Examining the Overlap between Restorative Justice and Behavior Analysis. Behavior Analysis in Practice, 15(4). doi:https://doi.org/10.1007/s40617-021-00632-1.
Sameera, V., Bindra, A. and Rath, G.P., 2021. Human errors and their prevention in healthcare. Journal of Anaesthesiology, Clinical Pharmacology, 37(3), p.328.
van Baarle, E., Hartman, L., Rooijakkers, S., Wallenburg, I., Weenink, J.-W., Bal, R. and Widdershoven, G. (2022). Fostering a just culture in healthcare organisations: experiences in practice. BMC Health Services Research, 22(1). doi:https://doi.org/10.1186/s12913-022-08418-z.
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