Risk Management, Human Fallibility, and Just Culture Essay

This essay delves into the critical aspects of risk management, human fallibility, and the implementation of a just culture within a healthcare setting, specifically using BMI Albyn Hospital as a case study. The introduction establishes the concept of risk and its management, emphasizing the importance of proactive measures to minimize potential losses and ensure organizational success. The main body of the essay explores the nature of human fallibility, differentiating between human errors (skill-based errors and mistakes) and violations, and illustrating these concepts with examples from the healthcare industry, such as misdiagnosis, delayed diagnosis, medical errors, infections, and low-quality medical devices. The essay then introduces the concept of a just culture, contrasting it with a blame culture and focusing on the restorative and retributive justice approaches, using the restorative approach adopted by BMI Albyn Hospital as an example. The conclusion underscores the significance of risk management in organizational success, highlighting the benefits of a just culture in fostering employee loyalty and minimizing errors. The essay provides a comprehensive analysis of risk management principles and their practical application within a healthcare context, supported by relevant literature.

Risk Management

Table of Contents
INTRODUCTION ..........................................................................................................................2
MAIN BODY ..................................................................................................................................2
Point One-...................................................................................................................................2
Point Two-...................................................................................................................................4
CONCLUSION ...............................................................................................................................5
REFERENCES................................................................................................................................7

INTRODUCTION
Risk refers to the uncertainty that might occur in the future due to the happening of an
undetermined event that might have the chance of having losses. It can be considered either
optimistically or might be a negative threat (American Diabetes Association, 2018). The risk
management is the procedure to identify the risk associated to a particular task or project in
advance and taking preventive measure for minimising impact of such risk. The purpose of risk
management is to identify the risk and mitigate its effect. It is a best tool to fight against any
uncertain tragedy for which the organisation was not ready. It reduces the possibility of having
losses, helps organisation in earning higher returns and ensures success. Risk management in
health care industry includes safeguarding their patients, taking proactive steps for risk
elimination, detecting clinical and administrative errors and reducing its impact.
For obtaining awareness regarding risk management and to study its concepts and
applicability, the chosen organisation is BMI Albyn Hospital. It is private hospital located in
Albyan Palace, Aberdeen, United kingdom and is covered in health care industry. This essay
comprises of detailed discussion relating to the applicability of human errors and risk arising due
to the same (Adam, T.R., Fernando, C.S. and Golubeva, E., 2015). Further it involves the
implementation of the gained knowledge and understanding of Just culture and its approaches.
MAIN BODY
Point One-
Human fallibility are the possibility of making mistakes by an individual or a group in
performing a particular task. Errors can occur to the best also, as no one is perfect in performing
all the tasks. There are number of human fallibility in health care industry such as, the nurse have
taken the wrong medicines from dispensary, resulting to the side effects to the patients, lost a
custody of an unlabelled specie or the surgery group skipped the pre-surgery time out resulting in
adverse effect on victim (Bodnar and et.al., 2019). Further human fallibility can be either due to
the human errors or because of violation.
Human errors refers to the mistakes done by an individual having no intention to do so. It
is the failure that occurred in planning the actions for achievement of desired goals. It can arise
due to the the poor management at work place, inadequate planning or because of the
carelessness of the employees (Chance and Brooks, 2015). These are the deviations in the actual

performance in comparison to the set standard performance. The two major type of errors are
Skill based error or Mistake. Skill based error happens due to the high routine workload. These
type of errors are mostly done by highly experienced individuals performance the similar task on
the regular basis. Such type of errors can be minimised by managing the fatigue effectively, by
using checklist style or by reducing external interference. Whereas, Mistakes occurs due to the
ineffective planning for achieving the desired results or because of lack of experience. It can be
minimised by providing the appropriate training, continuous supervision and motivating
employees (Chen, Ni and Tong, 2016). Further, violation in an act of breaking or not following a
rule and regulation or doing something unethical. These types of mistakes are being punished by
the law or any other senior authority. It is done with the intention of hurting someone or
destroying a property or asset that belongs to someone else. Few of the common errors in the
health care industry are as follows:
 Misdiagnosis- It happens when the incorrect diagnosis of a patient is done that results in
unrequited or harmful treatment (Constantinou and et.al., 2015). It means the true
problem of the patient is not cured instead a wrong treatment is made to him.
 Delayed Diagnosis- When the patient is not given a proper treatment on time leads to
delayed treatment. It may increase the probability that a person has to suffer more
because of the same (Hopkin, 2018).
 Medical Error- It is the most common type of error. Prescribing the wrong medicine or
the wrong dose is included in this type of error (Koulafetis, 2017). It may result in some
side effects, have harmful impact or allergy to the person consuming it.
 Infection- It is the risk that happens due to staying at the hospital or due to some medical
process. There are some cases where these infections results in the death or some serious
injury to the patient (Kramer, Kinn and Mishkind, 2015).
 Low Quality Medical Devices- Instruments such as IVC Blood clot filter, Bair hugger
surgical blankets, Stryker hip implants and other medical tools are required proper
sanitation after use otherwise it may have a dangerous impact of the patients health
(Meidell and Kaarbøe, 2017).
Point Two-
Just culture is a theory that relates to the system thinking concept having its major focus
on the mistake occurred rather then the person responsible for the happening of the uncertainty.

It is the reversal of the blame culture and aims at identifying the answer of the question of What
has happened wrong? Instead of centralising the attention on the one responsible for occurrence
of the problem. It treats the occurrence of issues as a failure of organisation's operational process
and not as an individual's mistake. It is a value supportive design, that creates a free environment
for the employees for reporting the errors. It also helps the company in learning form its mistakes
and not to repeat them in the future (Reamer, 2015). Just culture in the health care industry plays
a vital role are it develops a trustful environment for the workers and support for a fair treatment
if anything wrong happens with the care of patient. It creates an atmosphere that assures the
people to feel safe and report the errors or problems that might have a hazardous impact on
patient's safety. Its purpose is to treat the errors due to the failure of the operational process
rather then a personal mistake and intends to eliminate adverse results on the patient's life by
minimising the errors (Subramanian and et.al., 2016). For example, Let's consider a storyline,
where a medical assistant was sedating a victim suffering form seizure diseases. And abruptly
the patient was unconscious and was not responding and immediately needed a rescue breath.
Accidentally the patient was given the higher dose of the medicine, that was being required. So
the assistant immediately reported the same to the higher authority and focused on the curing the
patient. There are majorly three approaches of Just culture, which are explained below:
 Restorative Justice- It is one of the most important approach, that helps in establishing a
direct link among the offence and its impact. It makes the person accountable for his
action and organise a forum between the person who has committed the mistake and the
sufferer (Reim, Parida and Sjödin, 2016). It emphasises on solving the occurred problem
and minimising its impact. It creates a major responsibility and sense of liability for the
people involved. It involves questions like which rule is not fulfilled, who is responsible
for same, how he should be punished, who is hurt, what needs to be done for them and
who is responsible for meeting their needs. It focuses on what is the responsibility for the
wrong done and how to fix it. That solves the issue on the immediate basis.
 Retributive Justice- It is the model that offers achievement of both the learning and
accountable aspect. In this approach human errors, careless behaviours, at risk behaviour
etc. are responded in different manner as the problems relating to at risk behaviour are
being ignored and a training is given for the same and a careless or reckless behaviour are

severely punished (Sadgrove, 2016). It aims in finding the one who did wrong instead of
identifying the measures to solve the problem which leaves the issue unsolved.
In the context of BMI Albyn Hospitals, they follow the restorative approach of the just
culture for solving issues like providing wrong medicine to the patient or giving high
concentration of it and other such issues. By following this approach the problems and areas of
concern are solved in most efficient and appropriate manner. Also by following this model they
try to minimise the errors, and solves them by arranging a meeting between the manager, victim
and the person responsible for offence (Saeidi and et.al., 2019). It facilitates in coming to a
situation which is beneficial to all the parties involved. It helps in building a brand image of the
company and maintain its position in the competitive market. It also fosters in solving the issues
and giving best remedy. It facilitates the company in avoiding these similar mistakes in future.
CONCLUSION
From the above essay, it is analysed that management of the risk is a vital part for every
organisation and is directly linked to its success. It assists the management committee in
identification of the key issues, minimising its impact on the organisation and solving it in a
short time period and in the most efficient way. It boosts the moral of the employees and helps in
building loyalty. Just culture focuses on solving the problem on priority instead of blaming the
individuals. It helps in minimising repetition of errors to be occurred in the future. And it is
suggested for the organisations to follow this model as it will help in making a better brand
image.

REFERENCES
Books and Journals
American Diabetes Association, 2018. 9. Cardiovascular disease and risk management:
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Adam, T.R., Fernando, C.S. and Golubeva, E., 2015. Managerial overconfidence and corporate
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Bodnar, G.M. and et.al., 2019. A view inside corporate risk management. Management
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Chance, D.M. and Brooks, R., 2015. Introduction to derivatives and risk management. Cengage
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Chen, S., Ni, X. and Tong, J.Y., 2016. Gender diversity in the boardroom and risk management:
A case of R&D investment. Journal of Business Ethics, 136(3), pp.599-621.
Constantinou, A.C. And et.al., 2015. Risk assessment and risk management of violent
reoffending among prisoners. Expert Systems with Applications, 42(21), pp.7511-7529.
Hopkin, P., 2018. Fundamentals of risk management: understanding, evaluating and
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Koulafetis, P., 2017. Modern Credit Risk Management: Theory and Practice. Springer.
Kramer, G.M., Kinn, J.T. and Mishkind, M.C., 2015. Legal, regulatory, and risk management
issues in the use of technology to deliver mental health care. Cognitive and Behavioral
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Meidell, A. and Kaarbøe, K., 2017. How the enterprise risk management function influences
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Reamer, F.G., 2015. Clinical social work in a digital environment: Ethical and risk-management
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Reim, W., Parida, V. and Sjödin, D.R., 2016. Risk management for product-service system
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Sadgrove, K., 2016. The complete guide to business risk management. Routledge.
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