The investigation should focus on what happened and why. Was there a system problem, does a process need to be redesigned? Was it a competence issue and does the individual need education or a focused performance review?
If organizations decide a caregiver made a mistake due to risky behavior and needs coaching, care should be taken to make it relevant. Simply admonishing caregivers to "be more careful" is a waste of time. To effect change, coaching should focus on behaviors. For example, coaching a nurse through the process of medication administration and the steps the organization expects nurses to complete each and every time.
"The other thing is that competence is not optional," says Raso. "If you are in unit where you cannot demonstrate competent behaviors for that patient population despite education and coaching, then you can't continue to work there."
It's hard to separate emotions when something goes wrong, but "in a true Just Culture, it's not about the outcome at all," says Raso. "Whether the patient was harmed or whether the error never reached the patient at all, you still use the same principles."