What is a just assessment process?
A just assessment uses a standardized approach to evaluate in a systematic way the actions of people involved in a patient safety incident. In a just assessment, those who are involved in assessing healthcare workers:
Develop a timeline to see clearly how events unfolded over time.
Gather information about all the factors (system and individual) that may have influenced the sequence of events and the actions people took.
Consciously avoid four types of bias that affect how humans interpret events that happened in the past:
- Hindsight bias – viewing an event after the fact as avoidable (should have been ‘able to see it coming’)
- Illusion of free will – the belief that people are able to choose to be perfect and when actions were not perfect it is because of a conscious choice that an individual made
- Fundamental attribution bias – the act of committing an error is inappropriately attributed to some aspect of an individual’s personality or to a character defect (e.g., laziness or stupidity)
- Outcome or symmetry bias – the seriousness of the outcome is equivalent to the seriousness of the imperfect actions of an individual
Consider what another person with similar experience would typically do in this situation (substitution test). This provides insight into the usual way the actions are carried out.
Use all the information gathered about the healthcare worker’s actions and contributing factors to determine what an appropriate response is for those involved. A range of responses is possible depending on the circumstances.