16. Violations and Just Culture

Define violations

Deliberate, but not necessarily reprehensible-deviations from those practices deemed necessary to maintain the safe operation of a potentially hazardous system

• doesn’t always imply malicious intent or lack of safety concern

Define normalization of deviance

the gradual shift in what is regarded as normal after repeated exposures to “deviant behavior”

• routine violations

List the types of violations in practice (4)

1. routine

2. corporate

3. exceptional or necessary

4. Opitmization

define routine violations

• alternative, more efficient way of dealing with a task than what is required by policy at the expense of safety

• corner-cutting

Define corporate violations

results from decisions at the administrative level that creates a situation supporting violation of procedures

Define exceptional or necessary violations

occur in unusual or exceptional circumstances where a routine cannot be followed and an exceptional response is required

• Impossible or inadvisable to follow the typically good rule at that time

Define optimization violations

additional motives involved that go beyond task specific considerations supersede the primary motivation to engage in a task

3) Recognize violation-producing conditions in practice

There are several violation-producing conditions including inconvenient procedures, social pressure, permissive environment, and poorly designed systems

4) Explain how some violations can also be rule-based mistakes

Some violations are rule-based mistakes when that mistake (error of judgment) is a “bad” rule that violates a policy, procedure, or social norm

5) Explain “just culture”

Just culture recognizes the contribution of systems in error along with a focus on behavioral choices and accountability.

How an accountability tool can support “just culture'“

An accountability assessment tool supports an objective and transparent process for determining when an individual should be held accountable for actions or not.

6) Classify an action using “just culture” terms and determine the appropriate accountability for that action

• Individuals are held accountable for malicious, reckless, and risky actions (to the degree that the system is not set up to cause these) and they are not held accountable for unintentional errors.

Malicious action

Causing HARM

Reckless action

The choice is self-centered and has no social utility

• you know that you will be violating a rule and understand the risk of the unsafe choice

• you know that the behavior is not the norm

Risky (at-risk) action

The choice is based on the desire to help others and has social utility

• behavior is often the norm

• does not see the risk/mistakes the risk as insignificant or justified

Unintentional error

Making an error while working appropriately and in the patient’s best interest