A "Fair and Just Culture" supports learning from unsafe acts that result in potential or real harm as a way to prevent future errors. A fair and just culture strikes a balance between a punitive culture and a blame free culture. Differentiating acceptable from unacceptable behaviour associated with harmful events requires a consistent approach to determine culpability of individuals against system flaws that contribute to unsafe acts. More than one unsafe act by more than one individual can contribute to an event. For optimal learning and fair treatment of staff, each act should be considered individually using the same structured approach.
The following guideline will help to support a consistent and fair approach to the management of staff following events involving healthcare associated harm. It is based on the following premises:
- Healthcare is a complex and high risk activity prone to healthcare associated harm.
- Weak systems create the conditions for and the inevitability of human error.
- Latent conditions preceding adverse events include poor decisions, poor designs, poor supervision, inadequate tools and equipment, and the cumulative actions of individuals.
- Capturing, tracking and learning from healthcare associated harm is an essential step to safer care.
- A culture perceived as shaming, blaming and punishing of staff for unintentional harm is a major impediment to safety reporting and harm prevention.