The recognition of four different behavioral causes of individual provider error leads to a more “just,” and arguably more effective, response to each error event. The recognition and participation of members of the agency lead to increased trust in the CQI process and the eventual increase in self-reporting and the recognition and reporting of near-misses and process failures. The CQI personnel must first consider these behaviors: human error, negligence, reckless conduct, and intentional rule violations. (Box 6-5)
Box 6-5 Just Culture Behavior Types—Simplified Response Strategy
|Behavior ||Character ||Response |
|Human error ||Mistake—took wrong action (low culpability) ||Remediation (and evaluate for signs of impairment) |
|Negligence ||Failure to recognize a risk that should have been recognized (high culpability) ||Remediation (and possible discipline) |
|Reckless conduct (gross negligence) ||Conscious disregard of a significant visible risk (high culpability) ||Discipline (and remediation) |
|Intentional rule violations ||Knowingly and willfully broke the rule(s) (high culpability if associated with risk) ||Discipline if based on unnecessary risk |
This section describes the four types of behavior that contribute to commission of an error. It is important to note that a medical error may be related to the presence of one or more of these behavior types. Human error is when an individual is recognized as having done something other than the desired course of action, which then resulted (or could have resulted) in an undesirable outcome. Despite the outcome, these events need to be considered carefully, as they may be due to fatigue or knowledge gaps that could otherwise have been avoided, or can be avoided in the future. This type of error implies that the provider could not have detected the error prior to performing it and should result in a review and remediation to allow for improvements in the provider's performance. If the provider is found to have been impaired by substance abuse and/or emotional disturbance, they should be referred for appropriate medical and psychological care and counseling. Provider impairment is also discussed in Chapter 8. Negligence is the concept that the human error was performed by an individual that should have recognized the risk inherent to the action and is therefore culpable for the outcome. Reckless conduct is when the provider chose to disregard the risk, even when it was apparent to them, and is also known as gross negligence. Intentional rule violation is the act of knowingly and willfully acting in a way that is contrary to the rules, policies, or procedures. When a provider does this, they display their disregard for the authority of those who have established the rule and for those the rule is meant to protect. There are three ways to respond to these behaviors: outcome-based, rule-based, and risk-based decision making.
In outcome-based decision making, a provider would receive remediation and/or disability action based on the outcome of the error. Because of the tremendous potential for the provider to only be corrected when their errors result in harm, and the potential for a minor error to result in a major outcome issue, this is probably the least “just” and least prospectively effective method. For example, if an individual were to knowingly give an IV β-blocker multiple times during a transport and ignore the protocol requirement for cardiac monitoring and repeat blood pressures and the patient had no significant detected harm from the intentional rule violation and reckless conduct of the provider, then there could be determined little to no need to provide remediation of discipline and the providers would have no incentive to correct their behavior, potentially leading to future harm or death of a patient.
In rule-based decision making, a provider who breaks a rule is found to require remediation and/or discipline based on the infraction alone. This may have the desired outcome for the example provider above whose rule violation was risky and potentially life-threatening to his or her patient. However, if the breaking of the rule is judged on its own, then infractions of rules in an effort to comply with operational norms or patient needs may also result in remediation and/or discipline that does not suit the circumstances. For example, if a provider fails to fully restock the ambulance after a call with nonessential items in order to respond from the hospital to a high-priority call for which there is no other available unit, that provider has knowingly committed an intentional rule violation. However, this behavior is more beneficial to the patient and the system than strict adherence to that particular rule.
In risk-based decision making, the inherent risk of the behavior is the major factor in assigning the need for remediation and/or discipline, in that it focuses on the intent of a provider with regard to an undesirable outcome. Where a provider commits a human error there is no presumed level of inherent risk to their behavior and therefore was not an obviously preventable act. In a case where a provider commits gross negligence through reckless conduct they have committed an error with a high level of risk and would then be subject to remediation and discipline, possibly with the emphasis on the disciplinary action due to the grave nature of the knowing acceptance of risk toward the patient and the need for the agency to maintain standards among its providers. In the case of straight negligence it may be significantly unclear how much remediation verses discipline is warranted and there may be a need for both depending on the particular reason that the provider was unaware of the perceivable, yet unperceived, risk. The risk-based approach supports Just Culture as the preferred method on which to base these decisions.
The volume of work in this area is staggering and is beyond the scope of this chapter. However, those EMS physicians seeking to involve themselves in CQI at the system level and/or are involved in the active development of health policy should spend considerable effort toward achieving greater mastery of this area. Reviewing and understanding the work of Reason (Reason culpability Decision Tree, Reason Foresight test) and Hudson (Just Culture diagram) may enhance this process.23–25 College and graduate level classes, as well as webinars and seminars, are available on these topics.