There are a number of circumstances that compromise a clinician’s ability to provide safe care, such as unfollowable policies, malfunctioning equipment, or culture of blame when something goes wrong. In some cases, these system-based factors force clinicians to step outside of the standard of care. Panelists will discuss how to apply the Just Culture framework to inform improvements when the standard of care is not followed and will describe the data that can identify system failures before harm occurs. 

Moderator: 

• Lisa Morrise, MA, Executive Director, Consumers Advancing Patient Safety

Panelists: 

• Nico A. Kaptein, MA, Maruda Executive Director, Associate of COT Institute for Safety, Security and Crisis Management, Affiliated Teacher at Northumbria University
• Laura Herrero, PhD candidate, Telecommunications Engineer, MS Innovation Management, MS Business Administration and Information Technologies, Innovation Manager and Clinical Human Factors Researcher at IDIVAL- Valdecilla Biomedical Research Institute, Spain
• Robin Betts, RN, CPHQ, MBA-HA, Vice Chair, Patient Safety Movement Foundation, Vice President, Safety, Quality & Regulatory Services, Kaiser Foundation Hospitals and Health Plan, Kaiser Permanente Northern California

 Objectives:

• Discuss how systems can set up clinicians for failure. 
• Examine the drivers and impact of stepping outside of the standard of care. 
• Apply the Just Culture framework to evaluate decision making for systems improvement. 
• Describe the data that can identify system failures before harm occurs.