What Is Just Culture In Nursing

What Is Just Culture? Changing the way we think about errors to improve patient safety and staff satisfaction

“Just Culture” refers to a system of shared accountability in which corporations are accountable for the systems they have built and for responding to the behaviors of their workers in a fair and just manner. Employers hold their employees accountable for the quality of their selections, as well as for reporting faults and weaknesses in the system. In the case of Brigham and Women’s Faulkner Hospital, leadership is dedicated to cultivating a Just Culture in which patient safety is enhanced and our employees feel more confident in the decisions they are making.

Peggy Duggan, states, “We know that providing a secure and open atmosphere encourages the reporting of mistakes and dangers, which ultimately enhances the care we deliver to our patients.” However, according to the findings of our latest Safety Culture Survey, personnel at BWFH do not always feel comfortable speaking up when they witness anything that concerns patient safety and/or when they feel blamed when errors occur when they work in the hospital.

According to Dr.

“We’re working on putting up an infrastructure to support this technique,” said the Director of Risk Management and Compliance of the company.

  1. This is going to be a long process.
  2. Our just culture advisory group and advisors will be formed in the near future.
  3. So far, managers and supervisors have been invited to take part in the sessions.
  4. As we learn to look at our job through a different lens, it becomes simpler and less difficult to do over time.
  5. “Working in a Just Culture provides you with greater confidence in the judgments you make.
  6. “For frontline employees, it boils down to more confidence in reporting and greater candor when it comes to mistakes.” Implementing Just Culture requires a shift in the way we think about our organizations, our processes, and our people.
  7. LeSage, on the other hand, feels that BWFH will be successful.
  8. As a result, I believe you are poised and ready,” he states.

Because of BWFH’s size, as a relatively small community hospital, it is in a unique position to complete the project more quickly than a truly large institution would. Staff members can find resources on our intranetBWFHconnect by visiting the Just Culture page.

The just culture way to patient safety : Nursing made Incredibly Easy

Ask an Expert is a department within the department of Ask an Expert. Nurse Lisa Lockhart is the Director of Emergency Services at KentuckyOne Health’s Saint Joseph Health System in Lexington, Ky. She is also the author ofNursing Made Incredibly Simple! Member of the Editorial Board. The author has revealed that he has no financial ties that are linked to the subject of this essay. FigureQ: What exactly is “just culture”? A: A fair culture promotes responsibility and quality via the improvement of procedures and systems in the workplace, according to the author.

  1. Every employee is held accountable for patient safety and the quality of his or her practice decisions; however, the emphasis is on system design rather than placing blame on individuals for individual errors.
  2. In order to achieve this, all levels of the company must be committed to open communication and prepared to let go of any preconceived assumptions about the importance of error reporting.
  3. Building trust begins with the establishment of organizational norms and practice standards that are relevant to all layers of the organization and are based on common values and an articulated and enforced mission statement.
  4. This implies that every person of the company is aware of the strategic plan and understands what is expected of them.
  5. Human mistakes, at-risk behaviors, and irresponsible behaviors are the three types of behavior that might occur.
  6. These are controlled by resolving the underlying cause, examining the process, and correcting the deviation—not by correcting the individual.
  7. Working around the medication administration policy, for example, by giving medication under the name of a different patient in an emergency situation, or failing to scan a drug when the scanner would not “accept” the patient’s band but delivering the medication regardless, are also examples.
  8. When someone engages in reckless activity, it is necessary to correct them.
  9. Progressive punishment should be used to handle this type of conduct, which should begin with re-education on policies and procedures, as well as the reasons for which they are in existence.
  10. Staff that aren’t frightened to disclose errors are more likely to report them, which is a very successful strategy for improving patient safety, staff satisfaction, and overall outcomes.

Good communication, effective resource management, and the establishment of a strategy for guaranteeing the safety of patients and staff are all essential components of success. Wolters Kluwer Health, Inc. retains ownership of all intellectual property rights.

Developing a Just Culture

When you hear the phrase “just culture,” what is the first thing that springs to mind? As an example, consider the following dilemmas:

  • The phrase “just culture” evokes a variety of responses in people. Let’s have a look at the following situations:

In this section, we will discuss a few examples of difficulties that may be handled using the idea of a just culture. Just culture refers to a form of shared accountability that is based on shared ideals. It is a culture that holds companies accountable for the processes they develop as well as for how they respond to employee actions in a fair and just manner, among other things. Additionally, employees are responsible for the quality of their decisions as well as for reporting both their own faults and system vulnerabilities to the appropriate authorities (Griffith, 2009).

The recognition that many individual or active mistakes are the result of predictable interactions between human operators and the system in which they operate is also part of a just society.


These are as follows:

  • We must shift away from viewing mistakes as individual failures and instead recognize that they are the result of system problems. A transition from a punishing atmosphere to a fair culture is required. We must make the transition from secrecy to transparency. Health care must shift from being provider-centered (i.e., doctor-centered) to being patient-focused. We must shift our care delivery models away from relying on autonomous, individual performance excellence and toward interdependent, collaborative, interprofessional cooperation instead. Accountability must be widespread and reciprocal, rather than imposed from the top.

Accidents occur as a result of mistakes made by individuals. Accidents result in the death of people. The conventional response is to point the finger at the individuals involved. But, if we track out the perpetrators of the errors and penalize them, are we actually correcting the problem? No. The problem is almost never the fault of a single individual; rather, it is the fault of the system as a whole. People must be changed, but the system must also be changed, or the issues will persist. How can we make systemic changes that will encourage people to disclose errors and learn from their missteps in the future?

Individually responsible practitioners should not be held liable for system failures over which they have no influence.

Rather than being problems to be rectified, events are opportunities to get a better knowledge of the system.

It is necessary to have an administration that supports the ideals of a fair culture and encourages employees to bring faults to their attention.

Highly dependable industries encourage its employees to be conscious of their surroundings. As stated by Weick and Sutcliffe (2001), mindfulness is comprised of the following 5 elements or components:

  • Even in the most successful enterprises, there is a persistent worry about the risk of failure. Respect for expertise, regardless of one’s position or standing
  • It is a dedication to resilience that allows you to adjust when the unexpected happens. The capacity to concentrate on a single activity while maintaining a sense of the larger picture (operational sensitivity)
  • The capacity to adjust and flatten hierarchy according to the needs of the scenario

Health groups are now drafting and advocating policies and papers that are solely focused on culture. The Joint Commission leadership standards (Schyve, 2009) address issues of leadership and safety that are special to the organization’s governing body and its members (the CEO and senior management and medical and clinical staff leaders). Instituting an organizationwide policy of transparency that sheds light on all adverse events and patient safety issues within the organization, thereby creating an environment where everyone feels comfortable discussing real and potential organizational vulnerabilities and supporting one another in an effort to report vulnerabilities and failures without fear of retaliation, according to the Joint Commission (formerly JCAHO).

Just Culture and Its Critical Link to Patient Safety (Part I)

Believe your organization runs inside a Just Culture, or do you believe otherwise? In the course of our collaborative efforts with healthcare organizations and experts in pursuit of our common aim of minimizing drug mistakes, we have asked ourselves this question several times. Answering this issue is not straightforward, and it is mostly designed to stimulate fruitful discussion on the subject. Despite this, we frequently obtain fast affirmative replies, particularly from organizational executives, telling us that the organization has, in fact, built a Just Culture, despite the fact that our firsthand observations contradict such assurances.

Several components of an organization’s values, justice (equity to the workforce), and safety, as well as the design of safe systems and the establishment of a reporting and learning environment, are frequently examined in order to determine how far along the organization is on its journey toward a Just Culture.

Despite the fact that they are neither exhaustive or adequate in and of themselves to presuppose a Just Culture, the questions that follow might assist you in assessing your progress on this path.

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Table 1 shows some of the findings from the AHRQ Hospital Culture Survey Report from 2012.

Organizational Values

What are the fundamental and secondary values held by the organization? The core (high) and secondary values of a company working under a Just Culture have been developed in order to guarantee that employees understand how to prioritize their job assignments. Safety should always take precedence over all other considerations. Values such as efficiency and productivity should be regarded as secondary considerations. Overzealous dedication to these and other secondary values can endanger worker safety and cause confusion, particularly if workers are not given clear instructions on which value takes precedence.

  • Despite this, 26 percent of respondents from hospitals that took part in the AHRQ culture study stated that as pressure mounts, management want staff to work quicker, even if it means using shortcuts to accomplish their goals.
  • Do managers’ actions and attitudes suggest that safety is a major (and high) priority?
  • The open discussion of safety as a high value, as well as watching leaders and managers act in a manner that displays that safety comes first, promotes and supports staff decisions to do the same thing.
  • Behaviors that communicate conflicting messages (e.g., safety against productivity) cause confusion and encourage people to engage in risky conduct.
  • Patient safety has been elevated to the top of the priority list for many healthcare institutions, and it is deserving of their full focus right now.

Patient safety should be a long-term main value associated with every healthcare goal, rather than a secondary value that can be reordered in response to competing demands or other factors.

Justice and Safety

What actions does the company take in the event of a human error, at-risk conduct, or recklessness? Human error, at-risk behavior, and reckless conduct are the three categories of behavior that should be anticipated in an organization: human error, at-risk behavior, and reckless behavior. Because each form of conduct has a distinct source, each sort of response is distinct as well. Human error is defined as unplanned and unexpected conduct that results in or has the potential to result in an unfavorable consequence; it is not a decision on our part; we do not choose to create mistakes.

  1. Due to the fact that the employee did not plan to engage in the behavior or to experience any negative consequences as a result, discipline is neither justified nor helpful.
  2. Unfortunately, the AHRQ survey results reveal a different reality in many hospitals, as revealed by the results of the study.
  3. In contrast to human mistakes, at-risk actions are distinct from them.
  4. What is essential to us is often determined by the immediate desired outcomes, rather than by long-term or unknowable repercussions.

These potentially dangerous habits, which are frequently the standard among groups, are referred to be “the way we do things around here.” A Just Culture does not punish people who participate in at-risk activities; rather, it seeks to find and fix the system-based causes of their behavior while simultaneously decreasing staff tolerance for taking risks through coaching.

  1. They act on purpose and are unable to provide an explanation for their actions (i.e., do not mistakenly believe the risk is justified).
  2. The action reflects an intentional decision to disregard what they are well aware is a significant and unacceptable danger to their safety.
  3. Therefore, it should be dealt with in accordance with the organization’s human resources rules, either through remedial or disciplinary measures.
  4. The individual accountabilities of all employees in organizations that operate under a Just Culture have been developed and communicated to ensure that all employees understand what is expected of them.
  5. They are responsible for making safe behavioral choices and making judgments that promote safety in their environments.
  6. Identifying and managing everyday risks as well as coaching individuals who are engaging in at-risk behaviors are additional responsibilities for managers and administrators.
  7. In a Just Culture, all employees are aware that safety is a top priority in the firm, and they are always on the lookout for dangers that might pose a threat.
  8. When analyzing risk and mistakes, can the potential or actual severity of a consequence have a part in how personnel are handled in terms of how they are treated?
  9. In lieu of this, employees are evaluated based on the quality of their behavioral choices rather than the consequence or possible outcome of an incident or mistake.

If an error occurs, employees should be confident that they will be treated fairly when they disclose their errors, and that they will be held accountable for the quality of their choices rather than merely the consequence of their decisions.

Management of At-Risk Behaviors

Human mistake, at-risk conduct, and irresponsible behavior are all occurrences in which the organization must respond. Human error, at-risk behavior, and irresponsible conduct are all sorts of behavior that should be anticipated in any organization: Due to the fact that each form of conduct has a unique cause, each sort of response is necessary. Human error is defined as unplanned and unpredictable conduct that results in or has the potential to result in an unfavorable consequence; it is not a decision made by the individual; we do not choose to make mistakes; it is not a choice made by the organization.

  1. Because the employee did not intend the behavior or any unpleasant outcome that ensued, disciplinary action is neither required nor beneficial.
  2. In many hospitals, the results of the AHRQ survey, however, reveal a different reality.
  3. Human mistakes are not the same as at-risk behaviours.
  4. What is essential to us is often determined by the immediate desired goals, rather than by long-term or unpredictability of the consequences.
  5. In many cases, these high-risk activities are accepted as “the way things are done around here,” and they are often the standard among certain groups.
  6. Employers who engage in risky activity are more aware of the danger they are putting their company at than those who engage in at-risk activities.
  7. Other people are not participating in the conduct, and they are aware of this (i.e., it is not the norm).
  8. Risky activity is seen to be blameworthy in a Just Culture.
  9. Job descriptions, performance assessments, and/or policies documenting and communicating individual accountabilities are in place, and personnel is aware of their responsibilities.
  10. In a Just Culture, employees at all levels are held accountable for performing at the maximum degree of personal reliability while remaining cognizant of their own limits as individuals.
  11. They are in charge of detecting patient safety and other organizational hazards, such as system vulnerabilities, human mistakes, at-risk behaviors, and irresponsible actions, among other things.

They must continually assess the behavioral choices of their employees, monitor systems and processes, design and redesign systems to improve safety and security procedures, investigate the causes of risk and errors, and respond fairly and consistently to employees who make human errors or engage in at-risk, reckless, or erratic behaviors are additional responsibilities for managers and administrators.

Employees that work in a Just Culture are aware that safety is a top priority in the company, and they are always on the lookout for issues that might pose a threat.

When analyzing risk and mistakes, does the potential or actual severity of a result have an impact on how employees are treated?

In lieu of this, employees are evaluated based on the quality of their behavioral choices rather than the actual or possible consequence of an accident or hazard occurrence.

If an error occurs, employees should be confident that they will be treated fairly when they disclose their errors, and that they will be held accountable for the quality of their decisions rather than merely the consequence of their actions.

Part II

In one of our newsletters in June 2012, we will discuss the components of a Just Culture that are linked with system design, as well as the establishment of a reporting and learning environment. With the questions posed above and those in Part II, we hope that businesses would take a close look at their own organizational cultures and how they relate to what we call a “Just Culture” or “Just Culture-like environment.” It is far more than a fashionable metaphor for what was previously referred to as “non-punitive” or “blame-free” culture.

It is a comprehensive collection of principles, attitudes, and activities that give strong direction on how an organization may manage safety to the greatest extent possible.

(117-L05, 118-L05).

Why Accountability Sharing in Health Care Organizational Cultures Means Patients Are Probably Safer

The fact that human errors should be treated as normal occurrences requires health care organizations to formalize mechanisms for human error prevention, reduce negative repercussions when human errors do occur, as well as assist and educate people who have made mistakes. Those who err should only be punished if they have done so intentionally and irreversibly harm to others, according to a just culture perspective, because punishment fosters blame-based workplace cultures that discourage error reporting, so putting patients’ safety at risk.

A Case of One Kind of Medication Error

Despite their best efforts, physicians and other health-care professionals will unavoidably make errors, whether by omission or conduct, or simply as a byproduct of human nature and the faults of their work surroundings. One such example comes from Tennessee, where a recent case reveals a prescription error that might be used as the foundation for an investigation into responsibility in health care. The following are the specifics of the case: An elderly woman who was apprehensive about a scheduled positron emission tomography (PET) scan was administered midazolam hydrochloride to assist her feel more at ease owing to her claustrophobia, according to her doctor.

The override function of the dispenser allowed the nurse to choose the first medicine result shown, disregard a sequence of five pop-up warnings, and remove the selected (wrong) drug—a paralyzing agent—from the cabinet.

The patient was discovered to be in cardiac arrest thirty minutes later.

The patient was taken out of the operating room and died shortly after.

Codes and Cultures

As part of the investigation of this drug mistake, the codes of ethics of two organizations may be used to reveal fundamental characteristics of organizational cultures in health care that can be used to determine what could be an acceptable reaction. According to the Code of Ethics for Nurses, “while ensuring that nurses are held accountable for individual practice, mistakes should be addressed or remediated, and disciplinary action should only be taken when appropriate” 3According to the American Nurses Association, responding punitively to nurses who make mistakes, such as terminating their employment or prosecuting them with a crime, may not be necessary since “criminalization of medical errors might have a chilling impact on reporting and process improvement.” 4 Accountability for mistakes is emphasized both individually and collectively in the Code of Medical EthicsOpinion 8.6, “Promoting Patient Safety,” published by the American Medical Association (AMA).

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The report states that physicians, who are “uniquely positioned to have a holistic perspective of the treatment patients get,” should “strive to guarantee patient safety,” and that they should also “play a major role in the identification, reduction, and prevention of medical mistakes.” Moreover, according to Opinion 8.6, “both as individuals and as a profession, physicians should work to promote a good culture of patient safety, which includes compassion for their colleagues who have been engaged in a medical error.” The ethical statements from each of these organizations emphasize the significance of examining any physician activity, even a mistake, in light of the social and cultural environment in which that action was carried out.

Just Culture

Just cultureprovides a strategy for fostering healthy workplace environments in health-care environments. By striking a balance between “the requirement for an open and honest reporting environment and the end goal of a high-quality learning environment and culture,” 6,7 7 According to the Institute of Medicine’s 1999 report, To Err is Human: Building a Safer Health System,8 the majority of medical errors are caused by “faulty systems, processes, and conditions that cause people to make mistakes or fail to prevent them,” rather than by reckless actions by individuals working within those systems.

9 Because of this, the fair culture model acts as a guide for health care systems and organizations, encompassing features such as human factor design, error prevention, and efforts to control the repercussions of errors before they become life-threatening emergencies.

However, while a fair culture framework considers unfavorable result events as opportunities to better understand any underlying risks and how to avoid them, it does not absolve the organization of responsibility.

Under the framework of just culture, medical mistakes such as medication errors can be classified as simple human error (e.g., unintentional errors or lapses), as risky behaviors (e.g., “a conscious drift” toward actions in which the risks taken are unforeseen or mistakenly believed to be justified), or as recklessness, which is defined as the willful disregard of unjustified risks.

6,7 7 Corrective actions are centered on clinician behaviors rather than patient outcomes in the case of these errors. The recommended cures are, respectively, consolation, teaching to comprehend dangers, and punishment. 7

Cultures Compared

Just culture and law enforcement are both concerned with preventing harm to individuals or patients, as well as to property and public interests. Just culture places greater emphasis on the quality or desirability of an individual’s decisions and behaviors, and assigns corrective actions or punishment on the basis of those qualities or desirability rather than the severity of the consequences. Criminal law, on the other hand, is frequently concerned with outcomes. For example, while the law “generally disallows criminal punishment for careless conduct, absent proof of gross negligence” (ie, a heightened level of negligence that may include recklessness), some “legislations occasionally permit punishment based on ordinary negligence, primarily when the conduct is extremely dangerous and may cause harm to a significant number of people,” according to the American Bar Association.

10Just culture also makes an attempt to discriminate between different degrees of intent or culpability, which is more refined than the law.

7,11In its ambiguous interpretation of the different degrees of carelessness, such as “willful,” “wanton,” “reckless,” and “severe” negligence, which may include “recklessness,” criminal law frequently produces a “twilight zone.” Twelve, in a model of a just society, negligence includes both inadvertent errors (accidents) and dangerous activity (decisions), but not recklessness.

  1. 7 Just culture makes an attempt to discriminate between different degrees of intent or guilt in a more nuanced way than the law does.
  2. Adherents of the just culture perspective could point out that the nurse decided to ignore orders and warnings from the medicine cabinet and that she failed to confirm the medication, record the injection, and closely follow the patient.
  3. Despite the fact that the nurse made multiple blunders, they all started with a simple human error in picking the incorrect drug.
  4. Following in this line, some could argue that her choices and her understanding of risk, rather than the outcome, should be the most important factors in determining the appropriate reaction.
  5. Her attention may have been diverted elsewhere, such as to her trainee, for instance.
  6. This action might be considered hazardous, yet it would be considered natural in our culture.
  7. 11 Because the fair culture model considers “the inclination to drift” to be “part of our human nature,” minimizing at-risk behavior induced by “drifting” should be the primary emphasis of hospital patient safety initiatives while they are being designed and implemented.
  8. People who take the “finger pointing” position (for example, those who believe the nurse’s conduct were criminally irresponsible rather than merely erroneous) may, on the other hand, claim that the nurse’s activities were in fact criminally reckless rather than simply incorrect.

Her conduct may be compared to those of a car who is texting or speeding and hits and kills a pedestrian; both the driver’s and the nurse’s acts were deliberate rather than accidental, and the effects were foreseeably and preventably fatal.


The objective of minimizing mistakes, including human errors, is furthered by a culture and organizations that encourage communication and education while punishing only when necessary or appropriate. In accordance with the just culture model, individuals working within a system should not be held accountable for mistakes or choices they make if the system fails to prevent foreseeable errors; rather, health systems and institutions should positively guide anticipated interactions while actively participating in monitoring and reporting shortcomings in order to improve patient safety.


  1. The Centers for Medicare and Medicaid Services are part of the Department of Health and Human Services in the United States. Vanderbilt University Medical Center has issued a statement of weaknesses and a strategy for correcting them. lOMB 0938-0391. lOMB 0938-0391. The date of publication is November 19, 2018. Shelton C., accessed on July 17, 2020
  2. Shelton C. Multiple overrides result in the death of a former Vandy nurse, according to an investigation. Fox 17 is a television network that broadcasts in the United States. Nashville, Tennessee, March 27, 2019. The American Nurses Association has a website that may be accessed on July 9, 2020. 2015 edition of the Code of Ethics for Nurses includes interpretation remarks. Accessed on July 17, 2020
  3. The American Nurses Association replies to a Vanderbilt nurse incident. The American Nurses Association, Silver Spring, Maryland, published a new edition on February 19, 2019. Published on the 19th of February, 2019. The American Medical Association has a website that may be accessed on July 9, 2020. 8.6 out of 10 Increasing patient safety is a priority. In accordance with the Code of Medical Ethics. Published on the 14th of November, 2016. Patient safety and the “just culture,” according to Marx (accessed July 9, 2020). It’s Just Culture Community. It was first published in 2007. Boysen PG II
  4. Accessed on July 9, 2020
  5. Boysen PG II. Simply said, just culture is the building block for balanced responsibility and patient safety. Oschsner J.2013
  6. 13(3):400-406
  7. Kohn LT, Corrigan JM, Donaldson MS, eds
  8. Committee on Quality of Health Care in America, Institute of Medicine
  9. Committee on Quality of Health Care in America, Institute of Medicine. To Err is Human: Creating a Health System that is Safer. The Institute of Medicine published a book in 2000, published by the National Academy Press in Washington, DC. Brief summary of the report: To Err is Human: Creating a Safer Health System. Published November 1999
  10. Garfield, L.Y. To Err is Human: Creating a Safer Health System. A suggestion for the legislators on how to take a more principled approach to criminalizing negligence. Tenn Law Review, vol. 65, no. 4, 1998, pp. 875-924
  11. Marx, D. Reckless homicide at Vanderbilt? A fair and balanced examination of culture. Resulting in a creative solution. Published in March of this year. On the 9th of July, 2020, accessed E.H. Byrd. Reflections on the acts of deliberate, wanton, reckless, and extreme carelessness that have occurred. LA Law Review, vol. 48, no. 6, 1987, pp. 1383-1410.

Just Culture in Healthcare

The question is, who is to blame when a therapeutic mistake occurs at the hospital or in an ambulance. When anything goes wrong in the healthcare setting, healthcare organizations, the legal system, and patients have typically held the caregiver liable. The premise is that the individual who has been taught and licensed to give care is ultimately accountable for the quality of care that is provided to the patient or client. Getty Images TEK IMAGE / TEK IMAGE When considered as a group, healthcare practitioners are inclined to agree with this idea.

This is not exclusive to the healthcare industry.

Pilots, for example, have extremely limited margin for mistake, as do soldiers, firemen, architects, police officers, and a slew of other professions and occupations.

What Is Just Culture?

Despite the expectation of perfection, it is a well-known reality that humans are prone to making mistakes. Anyone who has ever misplaced their vehicle keys or failed to include a paragraph in a mid-term essay can attest to the reality that mistakes happen no matter how much knowledge we have or how routine the activity is may attest to this. Everyone makes mistakes from time to time, but the repercussions of making a mistake may be devastating in some instances. There has to be a method to decrease and mitigate errors for people whose acts have such a great weight tied to them.


Instead of placing blame on individuals, the fair culture approach emphasizes that mistakes should be accepted as unavoidable. It is impossible to make people completely infallible. It is possible, however, to identify known failure sites, and mechanisms may be designed to assist prevent making the same mistakes in the future. It is referred to as “just culture,” as opposed to “blame culture.” It is a shift in the way in which errors are seen and dealt with inside an organization. Caregivers in a company that promotes a fair culture are more likely to self-report errors or near misses, and the organization as a whole is more likely to have fewer bad occurrences.

Just culture views faults as systemic failings rather than as personal failures on the part of the individual.

This concept is applied on a daily basis in a variety of fields.

Modern nozzles are equipped with a breakaway coupler, which allows them to be pulled away from the hose without causing damage to the nozzle or the pump. This prevents this highly costly error from occurring.


A fair culture is designed to prevent unfavorable patient outcomes by eliminating mistakes, although the term “just culture” is inadequate for describing the notion. It has been suggested that, because this concept is referred regarded as “just culture,” there is a tendency to focus solely on addressing persons who make mistakes in a fair and just manner, rather to concentrating on the system or the environment in which the mistake was produced. The majority of the time, there are contributing elements that can be recognized and, in some circumstances, eliminated.

  • During a seizure, a paramedicis sedates a patient using sedatives.
  • Inability to awaken the patient, the paramedic must administer rescue breaths to the patient throughout the remainder of the journey to the hospital.
  • When a medication error occurs during an ambulance transfer, it is tempting to place the blame on the caregiver who made the mistake.
  • Because there is no disciplinary action taken against the caregiver, the administration may view this method to be reasonable and an example of just culture.
  • Then, what would be the underlying reason for anybody else in the organization to make the same type of drug error?
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System vs. Individual Focus

It is anticipated that a fair culture will minimize unfavorable patient outcomes by minimizing mistakes, however the notion needs a more appropriate term to convey its meaning. As a result of the labeling of this concept as “just culture,” there is a tendency to concentrate solely on treating persons who make mistakes in a fair and just manner, rather than concentrating on the system or environment in which the error was formed. It is usually possible to identify and, in some situations, eliminate the elements that are at play.

  1. It is not uncommon for the patient to become unconscious or unresponsive out of the blue.
  2. A larger concentration of medicine than was intended for the patient was mistakenly administered.
  3. In order to compare the caregiver’s education and experience with that of other carers, some administrators may begin to consider education or retraining as a possible remedial step.
  4. The assumption that the caregiver is equally competent, experienced, and well-trained as his or her colleagues is a more reasonable approach to taking.

Then, what would be the underlying reason for anyone else in the organization to make the same type of prescription mistake? The question arises when we look at a system rather than a person, as to why there are many concentrations of the same drug available aboard an ambulance.


You might be wondering when, if at all, the individual will be held responsible for his or her acts in this case. In a just culture, the person is held accountable not for faults in and of themselves, but for the choices they make. Take, for example, the paramedic who made the medicine error in our previous scenario. Were we ever going to hold him responsible for the overdose? Both yes and no. First and foremost, we would continue to repair the system flaws that created the chance for mistake.

  1. However, it’s critical to consider all of the elements that might have played a role in the paramedic’s miscalculation.
  2. Is it possible that he arrived at work exhausted?
  3. All of these elements might have played a role in the error, and they are all decisions that the paramedic would have to make on the basis of their experience.
  4. He’ll be able to tell if he didn’t get enough sleep before his shift started.

Outcome Bias

An critically crucial reminder concerning accountability: result doesn’t matter. It is not appropriate to hold a paramedic to a higher standard than he would be held to if the patient survived if the larger concentration of drugs was administered by mistake. In real-world situations, it is extremely difficult for regulators and administrators to combat outcome bias. When reviewing instances, it’s highly probable that the patient’s health was what prompted the investigation in the first place.

  • It’s quite simple to slip into the trap of “no damage, no foul,” which means “no consequences.” However, if the goal of just culture is to reduce the number of episodes that might result in negative results, the outcome of any particular event should not be taken into consideration.
  • A respiratory therapist aiding a resuscitation in the emergency department neglected to attach a sensor to the patient’sendotracheal tubeand the patient stopped getting oxygen.
  • She expresses gratitude to the nurse and connects the sensor, which alerts the rest of the team that the patient is not getting enough oxygen.
  • No one gives it a second thought because the patient turns out to be alright.
  • As an illustration of result bias, consider the following: The inaccuracy is the same in both versions, yet one is seen as a little blip on the radar while the other is regarded as a serious occurrence deserving of further investigation.
  • The objective of all caretakers would be to figure out how it is possible for the sensor to be accidentally turned off.
  • Perhaps the business would develop a checklist approach to assist identify faults that are readily ignored, such as this one.

Contributing behavioral decisions, on the other hand, would be taken into consideration. This may include holding the respiratory therapist accountable if she showed up to work weary or inebriated, for example.

Nurse Leaders Have Meaningful Role in Ensuring a Just Culture

By Maureen Schaupp, MSN, APRN-CNP, CHFN, Associate Chief Nursing Officer, Advanced Practice Nursing, Nursing Quality and Practice, Center for Health and Family Nursing Cleveland Clinic is a not-for-profit academic medical facility located in Cleveland, Ohio. Advertising on our website contributes to the success of our mission. We do not recommend or promote any items or services that are not provided by the Cleveland Clinic. Policy Caregivers at Cleveland Clinic are urged to participate in a just culture initiative in order to preserve and enhance safe practices.

Nurse leaders play a key role in ensuring that people and teams execute and apply the Cleveland Clinic’s fair culture strategy across the whole health system, according to the organization.

Nurse leaders contribute to Cleveland Clinic’s just culture in a variety of ways, including the following:

  • Making an atmosphere where all ideas, opinions and concerns are welcomed is a priority. modeling and reinforcing behaviors that build a culture of safety in the workplace Creating trust by establishing a positive and active tone and offering consistent feedback is essential. When caregivers report problems or possible errors, it is important to listen to them and offer assistance. Making it easier for teams to grasp why it is necessary and appropriate to spend the necessary time to resolve, report, and discuss problems
  • The use of fair and just practices throughout team interactions through the use of the organization’s just culture decision tree

Benefits of a just culture decision tree

Even though Cleveland Clinic has been following a just culture process for some years, the health institution has just implemented a new just culture decision tree to strengthen its commitment to patient safety. It is the purpose of a fair culture to guarantee that everyone who is engaged in a safety event learns from and understands why an error happened in order to prevent it from happening again in the future. An purposeful, objective technique to look at an occurrence and determine whether or not there is potential for change is provided by the Cleveland Clinic’s just culture decision tree.

It’s also about adhering to Cleveland Clinic’s fundamental principles and ensuring that caregivers are confident that their executives will back them when they speak up.

An inside look at Cleveland Clinic’s just culture decision tree

According to the Cleveland Clinic, the just culture decision tree was derived from research conducted at the University of Manchester and the National Health Service in the United Kingdom, and it is currently in use at the clinic. While it is based on non-punitive reactions to accidental error and blame-free reporting, people who act recklessly or take unreasonable risks may face disciplinary action as a result. The just culture decision tree, by standardizing the approach taken to safety events, facilitates dialogues between managers and caregivers about whether the response to a safety event necessitates system adjustments, specialized person assistance, or intervention in order to function safely.

In addition to six main topics or focal areas, the Cleveland Clinic’s just culture decision tree includes: Deliberate Harm: This tool assists managers in identifying the few instances when harm was intended at the earliest feasible stage.

Test for health: This test can be used to determine if an underlying medical condition or drug misuse contributed to or caused a patient safety event.

When a circumstance arises where what appears to be a feasible protocol first proves to be troublesome in reality, managers are notified.

Using the Substitution Test, you may determine how a peer might have reacted with the issue.

The Dangerous Behavior Test can assist in determining whether or not the activities committed would be regarded risky under any condition.

The term “mitigating circumstances” refers to unusual, unanticipated, and unpreventable occurrences that occurred that may have had an impact on the outcome that is being assessed.

Leaders also engage in culture refresher courses and other training activities that are made accessible to them.

Scenarios are offered for a wide range of caregiver groups, including pharmacy, facilities, engineering, nursing, and others, as well as for individual caregivers.

A single one had been made by her at the central nurse’s station, and it did not have a patient name or medicine label attached to it.

She imagined she had picked it up by accident at the train station.

Nurse leaders go through the just culture decision tree process in order to complete the training exercise and receive their certificates.

The nurse’s habit of bad decision-making would most likely be discovered by the time the nurse arrived at the risky conduct test in this case, as described above.

A safer environment for caregivers and patients

When caregivers understand the just culture process, it makes it easier for leaders and their teams to speak up, and it creates a more welcoming environment for learning. When this occurs, caregivers feel encouraged and included in the solution, which, in turn, has a beneficial influence on the quality of care offered to patients. Building a culture of safety is a strategic focus for the Zielony Nursing Institute and the Cleveland Clinic organization, according to the Cleveland Clinic. Being a strong advocate for safety by incorporating a just culture approach into everyday practice offers the most value for caregivers, patients, and patients’ families — and is an important component of the role of nurse managers and leaders.

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