Openness or Transparency
Openness is a critical factor in a culture of safety. It indicates that there is acceptance of human elements in error, and a conscious means of reporting any error, near miss, or identified potential for error. Openness is important so that errors and potential problems are exposed and handled before they endanger others. It is inherent that in a culture of openness, there is a “just culture” where retribution is limited to reckless or malicious behavior.
Lapses in Safety Procedures:
System flaws set up good people to fail. 80% of errors are system induced. People often find ways of getting around processes which seem to be unnecessary or which impede the workflow. This is known as Normalization of Deviance. Part of reporting should be documenting any time prescribed processes are circumvented. This provides feedback on what else needs to be changed.