Just Culture

In healthcare, it is inevitable that people will make errors. These errors will
result in morbidity, adverse outcomes and possibly a patient’s death. How an
organization investigates and responds to these errors is critical to creating
an environment that fosters patient safety. Medicine has traditionally engaged
in the name, blame and shame aspects of medical error.  The person responsible
for the error is named, blamed for the outcome and then shamed, which is somehow
supposed to encourage them to perform better next time.  This approach is
counterproductive and rarely generates improvement. It also creates an
environment where reporting errors and near misses is discouraged due to fear of
this process and lack of psychological safety. Unfortunately, this leads to
further adverse outcomes as institutions fail to learn from mistakes. Just
Culture requires a change in focus from individuals to one on healthcare systems
design.  A Just Culture realizes that most errors result from system
weaknesses.  The system may not be strong enough to:

1. minimize or, ideally, eliminate, the potential for human error
2. facilitate effective communication
3. minimize the risk of equipment failures
4. provide adequate staffing

When an error is deemed to be system-related then it is the responsibility of
the organization to improve the system. A Just Culture creates an open and
honest reporting environment. Involved personnel report mistakes and near misses
because critical event analysis is conducted transparently, is focused on the
systems, and encompasses the full complexity of the situation. Individuals trust
they will be treated fairly and, excepting substandard performance, celebrated
for bringing forth the issues.  A Just Culture also recognizes the need for
accountability when substandard performance is revealed. After a careful and
comprehensive review, if flawed medical decisionmaking or willfully negligent or
reckless behavior is identified, corrective or disciplinary action may be
warranted.

Examples:

1. A nurse selects the wrong vial of intravenous medication from the dispensing
   system. She draws up the medication.  She is about to administer it when
   bedside arm band scanning identifies the error.  She reports the medication
   wastage and near miss.  The event review showed that there were
   opportunities to improve the system to make error less likely. The intended
   medication and the one drawn up were “look alike”, “sound alike” medications
   – with packaging similar in size, shape, color and print and similar names.
   In a Just Culture, the nurse would not be punished for drawing up the
   incorrect medication.  Instead, she would be praised for reporting the
   “near-miss” and giving the organization the chance to improve the systems
   before a patient was harmed.
2. An attending physician directs a resident physician to order magnesium for a
   patient with preeclampsia. While they are logging in to place the orders,
   the resident is paged to an emergent delivery.  They hurry to place the
   orders and rush off.  Later, the first patient has an eclamptic seizure.
   The resident reviews the chart and realizes that they placed the orders on
   the incorrect patient.   The resident reports their error.  Full analysis of
   the event shows that the error resulted from systems weaknesses, including
   missed opportunities by other care team members to catch the error.  The
   resident is supported and recognized for reporting the error.  Improved
   communication among team members is promoted during the next round of
   simulations.

Reference Materials

Boysen PG 2nd. Just culture: a foundation for balanced accountability and patient safety.
Ochsner J. 2013 Fall;13(3):400-6. PMID: 24052772; PMCID: PMC3776518