The Online Newsletter for Children's Nurses
e-Edition, Issue 6
What is “Just Culture”?
Kris Aubry, MSA, BSN, RN, NE-BC - Director, Neonatal Intensive Care Unit and LuAnn Joy, BSN, RN - Director, Perioperative Services
The healthcare culture of the past fostered the habit of placing blame on care providers when an error or bad outcome occurred. This eventually led to the prevalence of punitive environments where occurrences were not being reported. To improve the reporting of errors, healthcare moved to a blameless culture. The blame free culture failed because organizational and individual accountability was diluted or lost and the practice did not promote a learning environment that promoted patient safety.3
A “Just Culture” balances the assessment of systems, processes and human behavior when an error or event is reported. The term “Just Culture” refers to a safety-supportive system of shared accountability where health care organizations are accountable for the systems they have designed and for responding to the behaviors of their staffs in fair and just manners. Staff, in turn, is accountable for the quality of their choices and for reporting both their errors and system vulnerabilities.1
“Just Culture” is an environment where negligence is identified and discipline is applied appropriately after a systematic review of the error. To ensure a fair and just process, an established set of objective questions follow an algorithm to identify if the error occurred due to a system or process issue and/or due to human error.1 Staff is held accountable for their actions or behaviors. Staff is held blameless when there is a system or process that allowed the error to happen.
By utilizing the “Just Culture” principles and decision-making algorithm, our organization can hold each person accountable and move away from an overly punitive or blame free culture and attain a middle ground with staff and systems. This model is designed to help change an organization’s culture by placing less focus on events, errors and outcomes, and more focus on risk, system design and the management of behavioral choices. In this model, errors and outcomes are the outputs to be monitored; system design and behavioral choices are the inputs to be managed.
The goal of a “Just Culture” environment is to design safe systems that will reduce the opportunity for human error and capture errors before they reach the patient. Safe systems should facilitate the staff to make good decisions and should make it more difficult to make an error. However, it is up to individuals to manage their behaviors and choices.
In this culture, we recognize that humans will make mistakes. It is the behavior choices that we must manage to make sure we do not drift into unsafe places. Humans must recognize that risk is everywhere and we have to be responsible for our behaviors. The behaviors we can expect to explore when assessing an event are human error, at risk, and reckless behavior.
- Human Error - inadvertent action; inadvertently doing other than what should
have been done; slip, lapse, mistake.
- At-Risk Behavior – behavioral choice that increases risk where risk is not recognized,
or is mistakenly believed to be justified.
- Reckless Behavior - behavioral choice to consciously disregard a substantial and unjustifiable risk. 2
Here is an example of these behaviors we may have or may not have done.
- You are driving in your car and you are preoccupied by other things. You are driving home and suddenly realize you never stopped at the stop sign near your home. (Human Error)
- You are running short on time and decide to drive faster to get to work. You are driving 75 miles/hour in a 65 mile/hour speed zone. (At-Risk)
- You decide to go faster and switch lanes franticly to move through traffic faster. (Reckless)
At Children’s, “Just Culture,” is a process for us to evaluate an error in a fair and just manner. This allows us to identify if the error included any of these elements: system design or process problem, human error, or, at risk behaviors. This process allows us to have an accountability system to evaluate events in an objective, transparent manner.
3. Leape, Lucian L.: Who’s to Blame? Joint Commission Journal Quality Patient Safety 36:150-151, April 2010
In This Issue
Pediatric Early Warning Tools
Patient Safety Survey
Informatics: The Language of Nursing
Nursing Peer Review
NICU Outreach Education
What is “Just Culture”?