title: Understanding and responding when things go wrong: key principles for primary care educators.
abstract: Learning from events with unwanted outcomes is an important part of workplace based education and providing evidence for medical appraisal and revalidation. It has been suggested that adopting a 'systems approach' could enhance learning and effective change. We believe the following key principles should be understood by all healthcare staff, especially those with a role in developing and delivering educational content for safety and improvement in primary care. When things go wrong, professional accountability involves accepting there has been a problem, apologising if necessary and committing to learn and change. This is easier in a 'Just Culture' where wilful disregard of safe practice is not tolerated but where decisions commensurate with training and experience do not result in blame and punishment. People usually attempt to achieve successful outcomes, but when things go wrong the contribution of hindsight and attribution bias as well as a lack of understanding of conditions and available information (local rationality) can lead to inappropriately blame 'human error'. System complexity makes reduction into component parts difficult; thus attempting to 'find-and-fix' malfunctioning components may not always be a valid approach. Finally, performance variability by staff is often needed to meet demands or cope with resource constraints. We believe understanding these core principles is a necessary precursor to adopting a 'systems approach' that can increase learning and reduce the damaging effects on morale when 'human error' is blamed. This may result in 'human error' becoming the starting point of an investigation and not the endpoint.
authors: a Medical Directorate , NHS Education for Scotland , Glasgow , UK.|b Institute of Health and Wellbeing , University of Glasgow , Glasgow , UK.
authors: Duncan
authors: D
authors: McNab
authors: a Medical Directorate , NHS Education for Scotland , Glasgow , UK.|b Institute of Health and Wellbeing , University of Glasgow , Glasgow , UK.
authors: Paul
authors: P
authors: Bowie
authors: c Dental School , Glasgow University , Glasgow , UK.|d Centre for Applied Resilience in Healthcare , St Thomas Hospital , London , UK.
authors: Alastair
authors: A
authors: Ross
authors: b Institute of Health and Wellbeing , University of Glasgow , Glasgow , UK.
authors: Jill
authors: J
authors: Morrison
mesh_terms: D004502:Education, Medical, Continuing / Q000592:standards*; D006282:Health Personnel / Q000193:education / Q000941:ethics; D006801:Humans; D007396:Internship and Residency / Q000941:ethics / Q000592:standards; D019300:Medical Errors / Q000941:ethics*; D061214:Patient Safety / Q000592:standards*; D058007:Physicians, Primary Care / Q000193:education* / Q000941:ethics*; D011320:Primary Health Care / Q000941:ethics* / Q000592:standards
keywords: Patient safety; adverse events; incident analysis; significant event analysis; system complexity; systems approach