Implementing Just Culture to Improve Patient Safety

ABSTRACT

Introduction

The number of deaths in the United States related to medical errors remains unacceptably high. Further complicating this situation is the problem of underreporting due to the fear of the consequences. In fact, the most commonly reported cause of underreporting worldwide is the fear of the negative consequences associated with reporting. As health care organizations along the journey to high-reliability strive to improve patient safety, a concerted effort needs to be focused on changing how medical errors are addressed. A paradigm shift is needed from immediately assigning blame and punishing individuals to one that is trusting and just. Staff must trust that when errors occur, organizations will respond in a manner that is fair and appropriate.

Materials and Methods

An extensive review of the literature from 2017 until January 2022 was conducted for the most current evidence describing the principles and practices of “just culture” in health care organizations. Additionally, recommendations were sought on how health care organizations can go about implementing “just culture” principles.

Results

Twenty sources of evidence on “just culture’ were retrieved and reviewed. The evidence was used to describe the concept and principles of “just culture” in health care organizations. Furthermore, five strategies for implementing “just culture” principles were identified.

Conclusions

Improving patient safety requires that high-reliability organizations strive to ensure that the culture of the organization is trusting and just. In a trusting and just culture, adverse events are recognized as valuable opportunities to understand contributing factors and learn rather than immediately assign blame. Moving away from a blame culture is a paradigm shift for many health care organizations yet critically important for improving patient safety.

"The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes." Dr. Lucian Leape¹

While the exact number of deaths in the United States as a result of medical errors remains controversial, what is clear is that underreporting is a common and challenging impediment to improving patient safety.^1–3 Evidence shows that one of the most significant reasons for underreporting is the fear of the negative consequences associated with reporting. In fact, fear is the most reported reason for underreporting worldwide.³ In the United States, some health care institutions are on the journey to becoming high-reliability organizations (HROs). HROs provide consistent excellence in quality and safety, over extended periods of time, reducing patient harm.⁴ Improving patient safety requires that HROs strive to ensure the culture of the organization is trusting and just.⁵ In a trusting and “just culture,” adverse events are recognized as valuable opportunities to understand contributing factors and learn rather than immediately assign blame. Moving away from a blame culture is a paradigm shift for many health care organizations.^6–9 The purpose of this article is to describe the critical role of a “just culture” with improving patient safety. Additionally, approaches to consider for implementing a “just culture” are provided.

“Just culture” is a concept that has been used for some time by industries such as aviation, train transportation, and nuclear power. However, the idea is relatively new to health care.^5,7 The principles of “just culture” require a shift in the way health care organizations have traditionally responded to adverse events.^5,8–11 In the past, it was customary for medical errors to be addressed by immediately assigning blame and punishing the individual involved. In turn, this resulted in the fear of the consequences and individuals not disclosing errors. With a “just culture,” it is acknowledged that errors do not occur only as a result of individual behavioral choices. Rather, errors also occur as a result of system failures.^9,10,12

Staff must feel psychologically safe and empowered to speak up when they observe others, or they themselves are personally involved in, causing a medical error.^10,11 When an individual is involved in an adverse event, a “just culture” requires understanding the behavioral choices the person made when considering remedies to the problem. The “just culture” approach promotes learning, managing behavioral choices, and designing safe systems to prevent the recurrence of adverse events. When using “just culture” principles, individuals recognize that when they report errors, fair treatment will be received.^9,12

Behavioral choices with a “just culture” fall into one of three categories: human error (e.g., unintentional errors, lapses in judgment, and forgetfulness), at-risk behavior (e.g., decreased awareness of risk and belief that the risk is insignificant or justified), and reckless behavior (e.g., actions that are knowingly counter to established standards and a conscious disregard of unjustified risks).^7,9,13 With human error, remedies should be aimed at consoling the individual, identifying ways to prevent a repeat situation, limiting negative consequences, and providing opportunities for education. With a “just culture,” individuals are not punished for at-risk behaviors. Instead, time is taken to coach individuals to understand how and why the incident occurred. Since reckless behavior is blameworthy, and the individual consciously disregarded risk, which is substantial and unjustifiable, appropriate disciplinary actions are taken according to organization policies and procedures to address the misconduct. Errors are always addressed by balancing system and individual accountability (Table I).^{7–9,12–14} The Veterans Health Administration’s National Center for Patient Safety developed the Just Culture Decision Support Tool (DST). The DST helps leaders to respond to errors in a way that is consistent with “just culture” principles of promoting fairness and balance between individual and system accountability.¹⁵ The section of the DST highlighting the above behavioral choices can be found in Figure 1.

CONSIDER THE FOLLOWING SCENARIOS

Scenario 1.Situation: When changing syringe pumps administering highly concentrated medications in the critical care setting, the standard operating procedure (SOP) is that this be performed by two nurses.¹⁶ A nurse chooses to forgo the SOP because the unit is very busy and short staffed. The rate of administration entered by the nurse was incorrect, and the patient received too much medication and required intervention to reverse the adverse effect. Application of Just Culture Principles: This behavior would be classified as at-risk. The nurse failed to follow the SOP believing the action was justifiable. In this case, the individual was accountable for the error. The appropriate remedy for this at-risk behavior would be to coach the individual to see the risk related to the choice made.¹³

Scenario 2.Situation: Two critical care nurses change a syringe pump administering a highly concentrated medication. The SOP was followed and the rate of administration entered was correct. The patient had an adverse reaction, reflecting the result of receiving too much medication, and required intervention to rapidly reverse the overdose. Following a root cause analysis of the adverse event, it was found that despite the nurses following the correct procedure, the infusion pump did not function properly. The device was overdue for preventive maintenance, which resulted in the malfunction. Application of Just Culture Principles: This event would be classified as a system problem. The problem was beyond the control of the nurse and, therefore, the individual was not held personally accountable. The nurse was consoled, and focus was placed on determining what system problems needed to be addressed. Understanding the circumstances of an error enables changes to be made to avoid a recurrence of similar errors.¹³

Scenario 3.Situation: A critical care nurse receives a physician’s order to begin a patient on a highly concentrated medication. The SOP requires that the medication be administered using a syringe pump. The nurse is busy and decides to forgo the use of the pump and administer the medication manually. The medication is administered too rapidly, and the patient’s condition deteriorates, requiring swift intervention. As a result of the adverse event, the patient’s hospital stay was extended by 5 days. Application of Just Culture Principles: The nurse knowingly acted counter to established standards, demonstrating little or no concern for the risk. As a result, disciplinary action was taken according to organization policies and procedures to address the wrongdoing.

Implementing “just culture” principles evolves over time and is not an easy process.⁵ As previously noted, a “just culture” requires a paradigm shift in how health care organizations address errors. The traditional punitive approach of assigning fault must be replaced with a method of understanding, as well as balancing system and individual accountability.¹⁷ There is evolving evidence for how health care organizations can go about implementing “just culture” principles. We advocate taking into consideration the following approaches.

ENGAGE LEADERSHIP

Implementation of a “just culture” can only take place if leaders are actively engaged in creating, encouraging, and sustaining change.^5,7,12 Leaders must be visible, accessible, approachable, and actively engaged with staff to understand any questions related to the culture change. Being actively engaged sends a powerful and valuable message to staff regarding the importance of improving patient safety.^5,7 Leaders should be strong role models. They are not infallible and should acknowledge when they have made a mistake.⁵ In order for a “just culture” to flourish, organization behavioral expectations must be clearly established by leaders and accountability (both individual and system) emphasized.⁷ A review process should be in place and followed in order to ensure that expectations are met.^9,12,17

SET EXPECTATIONS

While it is important to inform all staff about expectations, one of the foremost methods for doing so is discussing the meaning and significance of a “just culture” with new employees during the onboarding process.⁵ At this time, the discussion should be focused on the meaning and significance of “just culture.” From the very beginning, all employees should recognize and understand the important role they play in patient safety. In order to promote reporting of errors, employees should recognize that with a “just culture,” a balanced approach is taken to address errors in a manner that is transparent and fair. Setting clear expectations is key to creating and sustaining a culture of accountability.^5,12

REQUIRE ACCOUNTABILITY

Organizations employing “just culture” principles recognize that everyone is held accountable for their actions regardless of role, responsibilities, rank, position, etc. All staff are responsible for being situationally aware, mindful of patient safety, and speaking up when they have concerns related to patient safety.^7,18 Once the “just culture” concept is implemented into everyday practice, staff must be held accountable. One method for holding individuals accountable is by incorporating standards into annual performance evaluations.^5,7,12 Another aspect of accountability, which is oftentimes overlooked, is recognizing staff who speak up when they observe concerns related to safety, report good catches, and demonstrate being good stewards of “just culture” principles.^9,12,19 Reporting good catches and near misses are considered best practices for promoting and reinforcing a “just culture” and effectively improving patient safety.¹⁹

IMPLEMENT TRAINING

Critical to “just culture” implementation and sustainability is training. Training should cover information such as what “just culture” is, why it is important for patient safety, types of behavioral choices and appropriate remedies, and real-world examples of effectively responding to errors.²⁰ Training should go beyond mandatory sessions and is expected to be an ongoing process. “Just culture” lectures (in-person and online), small group activities, case studies, and scenarios are available through published materials²¹ and training courses.²²

ASSESS STAFF PERCEPTIONS

Assessing staff members’ perceptions of “just culture” is also essential. This assessment should be completed before and after the implementation of “just culture” principles and practices in order to measure change over time. One tool for measuring “just culture” in different health care settings, with varying disciplines, and most recently in nursing education, is the Just Culture Assessment Tool (JCAT). The JCAT is psychometrically sound and measures concepts such as communication and feedback, openness of communication, balance of a blame-free approach with individual and system accountability, quality of medical error reporting, and trust. The JCAT has been found to be instrumental in helping health care organizations and academic institutions to identify and direct resources needed for improving patient safety.^23,24

We believe that the importance of a “just culture” cannot be emphasized enough in the pursuit of patient safety. “Just culture” plays a crucial role in empowering staff across health care organizations to proactively monitor the workplace for potential safety issues. Proactive engagement fosters safety efforts and improves patient safety through the process of appropriately balancing system and individual accountability.

ACKNOWLEDGMENTS

None declared.

FUNDING

None declared.

CONFLICT OF INTEREST STATEMENT

None declared.

REFERENCES

Author notes