Guideline 1-800-50 - Quality Improvement: Just Culture Investigation

CMH EMS & MIH Protocols

Date of incident:

Date of investigation:

EMS incident number:

List of persons involved in investigation (this form should be completed with input from field staff involved in the incident).

What happened?

What normally happens?

What do policies and/or protocols require?

Why did the incident happen? Repeat this question as necessary to identify all the root causes.

Expand the appropriate algorithm(s) below and highlight the paths followed:

If an employee breeched the duty to avoid risk, complete the RISK ALGORITHM. Record result below:

No problems System problems Employee problems
  • NOT APPLICABLE
  • Do not consider employee action
  • Support employee in decision
  • AT-RISK BEHAVIOR: Coach employee and conduct at-risk behavior investigation -> Complete the BEHAVIORS ALGORITHM
  • Consider punitive action
  • HUMAN ERROR: Console employee and conduct human error investigation -> Complete the ERRORS ALGORITHM
  • RECKLESS BEHAVIOR: Consider punitive action -> Complete the BEHAVIORS ALGORITHM

If an employee breeched the duty to follow a procedural rule, complete the RULE ALGORITHM. Record result below:

No problems System problems Employee problems
  • NOT APPLICABLE
  • Support employee in decision to violate rule
  • Investigate circumstances leading to failure to know of duty
  • Investigate circumstances leading to impossibility
  • AT-RISK BEHAVIOR: Coach employee and conduct at-risk behavior investigation -> Complete the BEHAVIORS ALGORITHM
  • HUMAN ERROR: Console employee and conduct human error investigation -> Complete the ERRORS ALGORITHM>
  • RECKLESS BEHAVIOR: Consider punitive action -> Complete the BEHAVIORS ALGORITHM

If an employee breeched the duty to produce an outcome, complete the OUTCOME ALGORITHM. Record result below:

No problems System problems Employee problems
  • NOT APPLICABLE
  • Accept outcome
  • Support employee in decision
  • Investigate circumstances leading to failure to know of duty
  • Investigate circumstances leading to impossibility
  • Assist employee in producing better outcomes or consider punitive action

If there are repetative human errors, complete the ERRORS ALGORITHM. Record result below:

No problems System problems Employee problems
  • NOT APPLICABLE
  • Consider system redesign
  • Consider punitive action
  • Consider reassignment or termination
  • Employee to make better choices
  • Employee to remedy personal performance shaping factors

If there are repetative at-risk behaviors, complete the BEHAVIORS ALGORITHM. Record result below:

No problems System problems Employee problems
  • NOT APPLICABLE
  • Consider system redesign
  • Consider punitive action
  • Employee to remedy personal performance shaping factors

What system performance shaping factors can be improved (i.e. reducing the likelihood of human error or behaviroal drift)?

What employee improvements will be made?

Targeted chart reviews of the past 60 days are required to identify trends. What specific calls are going to be reviewed and by whom?

Citations:

Change Log:

DateLink to
previous
version		Description of change
10/20/20Added this guideline.
06/06/21pdfAdded expandable images instead of links to different pages. Moved to emsprotocols.online

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