Just Culture at DBTH: Our response to patient safety incidents

As a Trust, we always strive to provide the best possible care for our patients and a good experience at work for our people.

That being said, sometimes things don’t always to go plan. We recognise that mistakes and accidents can happen in any healthcare organisation or other setting, as we are all human, and what sets us apart is our dedication to learning from these experiences and enhancing patient safety and colleague experience.

**Marie Hardacre**, Associate Chief Nurse for Patient Safety and Quality

At DBTH, we are committed to delivering the highest quality of care to our patients and being a great place to work, and we recognise the vital role that a Just Culture plays in achieving this goal.

Just Culture is our commitment to fostering fairness, transparency and continuous learning throughout our organisation. By embracing Just Culture, we can create a supportive environment that empowers our colleagues to speak up and that will enable us to identify system vulnerabilities and promote continuous improvement. Our Board of Directors are committed to embedding a Just Culture approach.

Just Culture has four key principles which we should consider in our response to a patient safety incident:

Fair Accountability: We recognise the importance of accountability without unjust blame. Just Culture recognises that errors are often the result of system failures rather than individual negligence. We will encourage open dialogue and learning from these to implement preventative measures and avoid similar incidents in the future.
Learning and Improvement: We will not only identify and report errors but analyse reported incidents, near misses and other raised concerns to identify trends, patterns and underlying causes. Through this analysis, we can implement effective measures, continuously evolving and enhancing our practices for the safety of our patients.
Communication and Feedback: Open and transparent communication is at the heart of Just Culture. We encourage everyone to speak up, ask questions and share suggestions, concerns or ideas for improvement. Additionally, we will provide timely feedback on reported incidents and the subsequent actions taken.
Education and Training: Just Culture will be supported at DBTH by the national Patient Safety Incident Response Framework and we will provide comprehensive education and training for all colleagues who respond to such incidents.

As a Trust, we can all contribute to implementing these four key principles. Here is my pledge to support Just Culture, for our colleagues and our patients.