During the TCOM conference, Vice President, Outcomes & Evaluation, Analytics & Trainings Scott Fairhurst, PhD presented, “Building a Culture to Prevent Critical Incidents.”
Scott starts the presentation highlighting an example of someone accidentally overdosing while living in a residential facility, which is an example of a critical incident, and how the nightshift employee managed the moment. The critical incident review process was not focused on finding fault in the employee, but by identifying improvement recommendations that can prevent similar incidents in the future.
In creating a safety culture, sometimes called a just culture, Scott emphasizes that it is almost never a case of a person doing something wrong, but an opportunity to review and analyze critical incidents from a systems improvement lens. He says in describing critical incidents that, “part of a definition is that you review and analyze the system, not the person.”
Not only is it important to have a review process in place, but a corrective action plan in place as well.
