This document discusses establishing a culture of safety in emergency medical services. It notes that most medical errors are due to systemic issues, not individual mistakes. A "just culture" is proposed that is not focused on blame but rather shared accountability. Under a just culture, the organization is responsible for safe systems and processes, while employees are responsible for safe behaviors. Errors are categorized as human errors from flawed systems, at-risk behaviors where risks were unrecognized, or reckless behaviors with conscious disregard for risk. Different approaches are recommended for managing each type of issue, focused on system improvements, coaching, or discipline depending on the situation. An overall goal is to establish trust so that employees feel safe providing feedback to further improve safety.

1. To Err Is Human
Patient Safety
Your Safety
Our Safety

2. Culture of Safety
• 80% of medical errors are system‐derived
• Good people simply working harder will not
be sufficient to overcome the high complexity
inherent in EMS.
• Errors will occur
• The key is to design systems so that harm does
not reach the patient.

3. Reason’s "Swiss Cheese" Model
Reason, James. Human error: models and management. British Medical Journal 2000; 320:768‐770.

5. Culture of Safety
• The benefit of this approach to managing
behavior is that the process is up‐front and
transparent to the staff, which helps to achieve
trust.
• Risks become identified, reckless behavior isn’t
tolerated, and ultimately the organization is safer.
• In practical terms, today you are 3x more likely to
be involved in a MVC and 1,000x more likely to be
involved in a medical error than in an aviation‐
related incident, due in part to this cultural shift.

6. An Introduction to Just Culture
The single greatest impediment to error
prevention in the medical industry is
“that we punish people for making mistakes”
Dr. Lucian Leape
Professor, Harvard School of Public Health
Testimony before Congress on
Health Care Quality Improvement

7. Safe Culture
• The first and possibly most important step in promoting a safe
culture is the establishment of justice.
– Just Culture
– A system of shared accountability
– The organization is responsible for safe system and process design
– And employees are responsible for safe choices and behaviors
• This shifts an organization away from a “blame” culture.
• Why?
• Because to design safety, the organization needs feedback from
users (employees).
• To give feedback, employees need trust.
• An organization can establish this trust through a consistent and fair
approach to managing employee behaviors.

8. Establishment of a Just Culture

9. Establishment of a Just Culture
• Outcome Engineering of Plato, Texas defines these three
behaviors as follows:
• Human Error:
– An inadvertent action; inadvertently doing other that what
should have been done; slip, lapse, mistake.
– Product of current system design and behavioral choices
• At‐Risk Behavior:
– A behavioral choice that increases risk where risk is not
recognized, or is mistakenly believed to be justified.
– A choice, risk believed insignificant or justified
• Reckless Behavior:
– A behavioral choice to consciously disregard a substantial and
unjustifiable risk.

10. Establishment of a Just Culture
• Human Error:
– An inadvertent action; inadvertently doing other that
what should have been done; slip, lapse, mistake.
– Product of current system design and behavioral
choices
• Manage through changes in:
– Processes & Procedures
– Design
– Training
• Console

11. Establishment of a Just Culture
• At‐Risk Behavior:
– A behavioral choice that increases risk where risk is
not recognized, or is mistakenly believed to be
justified.
– A choice, risk believed insignificant or justified
• Manage through:
– Removing incentives for at‐risk behaviors
– Creating incentives for healthy behaviors
– Increasing situational awareness
• Coach

12. Requires A Change in Culture
“Treat every drug administration as if it’s
wrong and will kill the patient”
John Nance
• Suggested Meds:
– Narcotics, to include Ketamine
– Epi 1:1,000 vs Epi 1:10,000
– Mag Sulfate
– Any Pediatric Dose
– Rarely used medications [Diltiazem]
– All CCP medications

13. Establishment of a Just Culture
• Reckless Behavior:
– A behavioral choice to consciously disregard a
substantial and unjustifiable risk
• Manage through:
– Remedial action
– Punitive action
• Discipline

14. Accountability for Our Behaviors
Human Error At‐Risk Behavior Reckless Behavior
Inadvertent action:
slip, lapse, mistake
A choice: risk not
recognized or
believed justified
Conscious disregard of
unreasonable risk
Manage through
changes in:
• Processes
• Procedures
• Training
• Design
• Environment
Manage through:
• Remove incentives
for at‐risk
behaviors
• Create incentives
for healthy
behaviors
• Increase situational
awareness
Manage through:
• Remedial action
• Punitive action
Console Coach Discipline/Sanction

15. What do you see?

16. Just Culture – Not Blame
Also not carefree
• A just culture recognizes that individual practitioners
should not be held accountable for system failings over
which they have no control.
• A just culture also recognizes many errors represent
predictable interactions between human operators and
the systems in which they work; and recognizes that
competent professionals make mistakes.
• Also acknowledges that even competent professionals
will develop unhealthy norms (shortcuts, “routine rule
violations”).
• A just culture has zero tolerance for reckless behavior.

17. Wrong Medication Dose
Human Error At‐Risk Behavior Reckless Behavior
Inadvertent action:
slip, lapse, mistake
A choice: risk not
recognized or
believed justified
Conscious disregard of
unreasonable risk
“I drew up 4mg and
gave it IV, then
immediately realized
that it should have
been 0.4 mg”
“I would have double‐
checked with my
partner, but she was
out getting supplies,
and I wanted to get
the patient treated”
“I have everything
memorized and don’t
rely on cheat sheets
and can’t trust
another medic”
Console Coach Discipline/Sanction

18. Wrong Medication Dose
Human Error At‐Risk Behavior Reckless Behavior
Inadvertent action:
slip, lapse, mistake
A choice: risk not
recognized or
believed justified
Conscious disregard of
unreasonable risk
“I drew up 4mg and
gave it IV, then
immediately realized
that it should have
been 0.4 mg”
“I would have double‐
checked with my
partner, but she was
out getting supplies,
and I wanted to get
the patient treated”
“I have everything
memorized and don’t
rely on cheat sheets
and can’t trust
another medic”
Console Coach Discipline/Sanction

19. Wrong Medication Dose
Human Error At‐Risk Behavior Reckless Behavior
Inadvertent action:
slip, lapse, mistake
A choice: risk not
recognized or
believed justified
Conscious disregard of
unreasonable risk
“I drew up 4mg and
gave it IV, then
immediately realized
that it should have
been 0.4 mg”
“I would have double‐
checked with my
partner, but she was
out getting supplies,
and I wanted to get
the patient treated”
“I have everything
memorized and don’t
rely on cheat sheets
and can’t trust
another medic”
Console Coach Discipline/Sanction

20. RSI: Paralysis Without Sedation
Human Error At‐Risk Behavior Reckless Behavior
Inadvertent action:
slip, lapse, mistake
A choice: risk not
recognized or
believed justified
Conscious disregard of
unreasonable risk
“3 am call, very busy
night, I was tired”
“Patient had a head
injury and was
unconscious so didn’t
need sedation”
“Patient is demented
and won’t remember
anyway” or “I’ve
never had a patient
complain”
Console Coach Discipline/Sanction

21. RSI: Paralysis Without Sedation
Human Error At‐Risk Behavior Reckless Behavior
Inadvertent action:
slip, lapse, mistake
A choice: risk not
recognized or
believed justified
Conscious disregard of
unreasonable risk
“3 am call, very busy
night, I was tired”
“Patient had a head
injury and was
unconscious so didn’t
need sedation”
“Patient is demented
and won’t remember
anyway” or “I’ve
never had a patient
complain”
Console Coach Discipline/Sanction

22. RSI: Paralysis Without Sedation
Human Error At‐Risk Behavior Reckless Behavior
Inadvertent action:
slip, lapse, mistake
A choice: risk not
recognized or
believed justified
Conscious disregard of
unreasonable risk
“3 am call, very busy
night, I was tired”
“Patient had a head
injury and was
unconscious so didn’t
need sedation”
“Patient is demented
and won’t remember
anyway” or “I’ve
never had a patient
complain”
Console Coach Discipline/Sanction

23. Accountability for Our Behaviors
Human Error At‐Risk Behavior Reckless Behavior
Inadvertent action:
slip, lapse, mistake
A choice: risk not
recognized or
believed justified
Conscious disregard of
unreasonable risk
Manage through
changes in:
• Processes
• Procedures
• Training
• Design
• Environment
Manage through:
• Remove incentives
for at‐risk
behaviors
• Create incentives
for healthy
behaviors
• Increase situational
awareness
Manage through:
• Remedial action
• Punitive action
Console Coach Discipline/Sanction

24. Assume Good Intent
Just Culture – Not Blame. Also not carefree.
A just culture has zero tolerance for reckless behavior.