The Curious Case of the End Result

Law enforcement agencies could probably use a dash of Just Culture to mitigate sentinel events by removing outcome from their investigations.

Can we apply some points of Just Culture to law enforcement to make better organizations? I think so. Grab a seat.

Everybody understands that police officers by and large are good people. Less than one half of one percent tarnish the badge. But the bad ones seem to skate through their careers unscathed - until a sentinel event occurs. How do we change organizations to eliminate that one percent? How do we reduce the sentinel events? By eliminating outcomes from investigations on their own people that stem from adverse events.

By now most of the world has seen the Buffalo Police Department video, and I think it actually highlights the problem and potential solution to some of the problems plaguing the "bad apples" in policing. I'm going to introduce one of the concepts of Just Culture. When we look at errors in medicine under this lens we actually eliminate the *outcome* of the event, because what happened as a result bears minimal to no outcome usually on why the mistake occurred.

For example, when a wrong medication is given to a patient, whether nothing happens at all, or whether the patient dies doesn't change the fact that both scenarios need equal attention. We must analyze the system and sequence of events that occurred to make sure that error never repeats itself. The outcome is irrelevant to process change to solve the issue that led to that error - for example maybe the gravol and the epi look exactly the same, and under extreme stress that's just a bad idea. Whether the patient has no adverse event or had a fatal adverse event doesn't change the fact that we should probably do something to change packaging or labeling. We take action in medicine and healthcare *regardless* of the outcome. We look at both scenarios equally because we understand that one day that same error may result in serious harm, even if it didn't this time. This point is important.

Back to Buffalo. Eliminate the outcome. What if that old guy fell backwards on his ass, and got right back up and walked away. Would we be as outraged? Let me be clear... This isn't a discussion on whether or not they had the authority to push the old guy, or whether or not the force used was reasonable for the threat or lack of threat presented. That's an entirely separate debate. What I'm positing is that there would likely be no suspensions if he wasn't injured. What I'm getting at is in policing, there is no systemic change until something *big* happens and makes the front page of the news. Law enforcement agencies make changes based on what happened, not what *could* have happened. If George Floyd would have regained consciousness and been carted off to jail, there would be no news. There would be no protests. There would likely be no suspensions. But remove the outcome... It doesn't change the fact that kneeling on somebody's neck for ten minutes who isn't resisting anymore is inherently a bad idea and may cause significant harm or death. And by that event occurring even if George walked away fine, recognize that would still be a problem and change needs to occur in that organization because every officer knows that's not ok in the use of force continuum.

Would just culture apply carte blanche to law enforcement? Probably not. But I think there is some good concepts that could be applied to force some degree of change, and perhaps prevent some of these front page news stories by stopping sentinel events before they occur.