Book of the month: Just culture: balancing safety and accountability by Sidney Dekker (1st edition)

This is the second book by Sidney Dekker to be reviewed in this blog. (The first was his earlier book, "The Field Guide to Understanding Human Error"). This is a testament perhaps to both Dekker's readability and relevance to the patient safety movement.

About the author

Sidney Dekker is a Professor in the School of Humanities at Griffith University in Brisbane, Australia. He has published a raft of books on the topics of safety and failure. Dekker is also a pilot and therefore brings practical experience of the workings of a high-reliability industry to his writing.

Who should read this book?

"Just Culture" is aimed at anybody with an interest in how to bring about the conditions required to make the title of the book a reality, from individual practitioners to hospital managers to legislators. In terms of simulation centres, it will inform both your day-to-day debriefing skills, as well as your response to requests for the assessment of "bad" practitioners.

I haven't got time to read 149 pages… (but can manage 149 words)

Dekker's main argument is as follows:

1.  'Everybody' agrees that the incompetent or reckless individual should be held accountable
2. These individuals form a minority. The majority of errors are carried out by well-meaning practitioners who simply need re-training or support
3. Unfortunately the decision as to who is incompetent is:
1. Usually made "after the fact" and a number of biases may make it very difficult to consider the intent of the individual
2. Fraught with adverse consequences. Blame and potential criminal/civil legal proceedings may have the effect of reducing patient safety as adverse events become less frequently reported through fear of a similar fate.
4. To achieve a just culture one must find the answers to three questions:
1. Who gets to draw the line?
2. What is the role of domain expertise in the drawing of the line?
3. How protected are safety data from the judiciary?

What's good about this book

Dekker uses some very powerful true stories which illustrate the tension between safety and accountability. Primarily these are stories of individuals who have been used as scapegoats for systematic failings: A nurse convicted of wrongly preparing a drug infusion, a captain accused of putting his passengers at risk, a police officer shooting an unarmed man.

Dekker discusses how the legal system, which is meant to provide "justice", is very poor at grasping the complexities of individual cases. The atmosphere of a courtroom several years after a lethal error is very different from a busy intensive care unit and so it may be impossible to relay the multifactorial causes of an error by the person "at the sharp end".

Dekker also informs us of that something that many suspected, namely that even in aviation (a high-reliability industry where error-reporting is the norm) it is not unusual for senior pilots to withhold information if they think that they can "get away with it". The reason? According to Dekker's source:

"Because you get into trouble too easily. The airline can give me no assurance that information will be safe from the prosecutor or anybody else. So I simply don't trust them with it. Just ask my colleagues. They will tell you the same thing."

Dekker provides useful definitions of reporting (informing supervisors etc.) and disclosure (informing clients, patients, etc.) and why they are both important. He also discusses how errors are often sub-divided (after the fact) into technical errors (honest mistakes made while learning a task) and normative errors (mistakes made by people failing to fulfil their role obligations).

Lastly, Dekker provides us with a step-wise approach to developing a safety culture and encourages us to start "at home, in your own organisation".

What's bad about this book

Dekker uses a number of examples showing how things go wrong but the book is very sparse on incidents where a "just culture" worked. It would have been useful to see some practical examples of just cultures in healthcare.

Final thoughts

Dekker does not pretend that realising a just culture will be easy or quick. However he does make a good argument for aiming for a just culture, not only because it will be "just" and safer, but because it is likely to be good for morale, job satisfaction and commitment to the organisation (p.25)