Culture of Safety critical incident review

The Department of Human Services is using the Culture of Safety systemic critical incident review model to review critical incidents, such as medication errors and wheel chair safety incidents. The project began in May 2019.

Why is DHS using the Culture of Safety model?

To improve the quality of life and community participation/contribution of people with disabilities
To develop a robust and proactive response to critical incidents dedicated to accountability, learning and improvement of Minnesota’s systems, rather than assessing blame
To move beyond surface level understandings of how systems fail to an understanding of how various parts of a system worked together to influence undesirable outcomes
To develop recommendations for systemic changes to Minnesota’s home and community-based services system.

Culture of Safety
Review process
How to be involved

Culture of Safety

Culture of Safety is an approach that seeks to move a critical incident system away from a culture of blame and toward a culture of accountability. Years of research have shown that assigning blame might actually decrease accountability because it inhibits the ability of an organization to learn and improve.

The model draws from the same sciences that safety-critical industries, such as aviation and nuclear power, use to improve systems and develop a culture of safety. Advanced models engage employees in safety efforts, establish comprehensive approaches to analyzing adverse events and promptly act upon identified areas of improvement.

When our work addresses typical underlying systemic factors, our agencies and systems can begin to make critical advancements in promoting safe outcomes for people with disabilities, families and employees.

Read more about the science and evidence of the review model on the Collaborative Safety website.
Review process

The model reviews the following:
- Incidents that occur in Blue Earth, Clay, Dakota, Hennepin, Olmsted, Otter Tail, Polk or St. Louis counties
- Incidents that involve any disability type and people of any age
- Incidents that occur in a 245D-licensed setting or licensed settings with county lead investigative purview
- Incidents of the following types:
  - Elopements
  - Medication errors
  - Staff sleeping on duty
  - Use of prone restraint
  - Wheelchair safety issues
  - 245D service terminations.
Reviews will consist of a debriefing with staff involved with the critical incident and a systemic mapping of the incident, which will assess any systems issues that played a factor in the incident. Mapping teams will consist of state, county and provider staff.

Note: The critical incident review is a separate process and does not take the place of required mandated reporting or investigation of alleged maltreatment under Minn. Stat. §626.
How to be involved

There are two parts to the Culture of Safety project:
- Training opportunities for lead agencies, 245D provider organization and DHS to learn about safety science, accountability and the critical incident review process. DHS will promote trainings using DSD’s eLists and is working to create more ways to promote the available trainings.
- A 20-member team of safety analysts conduct incident reviews. As a 245D provider in one of the pilot counties within the review process scope, an incident from your organization might be selected and you might be asked to participate in the review process.