Improving Patient Safety by Promoting a ‘Just Culture’

Clinicians cite staffing shortages and patients concerns as reasons to work while sick.
Clinicians cite staffing shortages and patients concerns as reasons to work while sick.
Health care professionals should know they are accountable for their actions but also feel comfortable that they will not be blamed for systems errors that are beyond their control.

A patient is inadvertently given the wrong dose of an intravenous medication during hemodialysis that results in the patient’s transfer to the emergency department. The error was related to a miscommunicated verbal order between gowned and masked staff in a loud, busy treatment suite. Although the patient was stabilized and discharged later that day, the event was unnerving for the staff at the dialysis center. The nurse who administered the medication was feeling guilty about the adverse event and worried about feeling blamed for the error. The physician who ordered the medication felt responsible for the error and worried if this will lead to legal liability or affect their employment. The patient was upset about having to be transferred to the emergency room, but was more concerned about this problem happening to future patients.  The medical director of the dialysis unit was unsure how to productively and effectively promote patient safety on the unit going forward.  

For decades, health care staff have adopted the approach, borrowed from other major industries, to make safety a critical priority and recognize the central role of system errors in adverse events. Thankfully, the “bad apple” approach that singles out an individual as the cause and solution to medical errors has diminished in significance as more health care institutions recognize its serious flaws. This so-called “punishment model” explicitly punishes health care providers for medical errors, reduces the likelihood of open reporting of safety concerns and may lead to staff internalizing blame when an error occurs. Although health care professionals know intellectually that people will always make errors, acknowledging that fact and managing that reality continues to challenge them.1

From an ethics perspective, promoting patient safety consistently and effectively is an important duty health care professionals owe to patients. All health care professionals as part of their obligation to avoid harm and promote patients’ best interests should embrace and participate in patient safety quality improvement initiatives. How health care settings approach this goal matters because unproductive strategies may threaten staff’s and patient’s trust in health care.  First, if a “culture of blame” is perpetuated where health care professionals do not speak up about patient safety because they are afraid they will be blamed for doing so, then it will be harder to identify and address patient safety concerns. Staff should be empowered to raise these concerns because patient safety is everyone’s responsibility. Second, a punishment model is more likely to drive safety issues underground where they cannot be addressed, rather than in an open environment where leaders can promote solutions with the input of front-line staff.

Within the high reliability organizational model lies the concept of “just culture.” Just culture balances the need for continuous quality improvement using a systems approach to patient safety, with the importance of individual accountability. In other words, health care professionals should know they are accountable for their actions but also feel comfortable that they will not be blamed for systems errors that are beyond their control.2 If we lump all types of adverse events together, we miss the specificity needed to promote a just culture. 

To distinguish different types of adverse events and make the systems-based responses to them actionable and justifiable, patient safety experts have specified error by the degree of personal intent. The 3 main categories include human error, at-risk behavior, and reckless behavior. These distinctions help to differentiate the accountability of the main actors. For example, a root cause analysis may reveal that an adverse event involving a nurse or physician was the result of a systems problem (and therefore they are not accountable). Contrast that with a clinician who knowingly and deliberately tries to harm a patient (and thus is accountable).  Individual coaching and system changes as part of quality improvement are the just culture response in the former case, while disciplinary action or punishment might be an appropriate response in the latter one. In-between these scenarios lie the at-risk behavior when health care providers make unsafe choices often knowing that it violates a rule, policy, or standard operating procedure. These providers should be accountable for their deliberate choices, but also should be counseled on the error, their role, and how following the existing standard practice is designed to protect patients. Repeated at-risk behavior requires an individualized approach.

Large health systems in the US and internationally, the Institute for Healthcare Improvement, and other organizations have developed useful algorithms to promote fairness and consistency in addressing adverse events by balancing accountability with a systems focus.3 Algorithms draw on information about intent, foresight, and comparison to similarly situated colleagues.  They include a combination of the following questions:  Did the individual intend to cause harm? Was the individual physically or mentally impaired? Did the individual knowingly and unreasonably increase risk by departing from safe and available protocols, procedures, or policies? Would another similarly trained, qualified individual act in a similar manner?

Although some adverse events may never be able to be completely avoided, how health systems learn about and respond to them can create an environment where they become increasingly unlikely. With an obligation to protect patients and participate in efforts to minimize harm, embracing and supporting open reporting and fair and consistent management of safety concerns is a worthy goal that deserves the attention of all health care professionals.

David J. Alfandre MD, MSPH is a health care ethicist and an Associate Professor in the Department of Population Health at the NYU School of Medicine in New York. The views expressed in this article are those of the author and do not necessarily reflect the position or policy of the VA National Center for Ethics in Health Care or the US Department of Veterans Affairs.


  1. Boysen PG. Just culture: a foundation for balanced accountability and patient safety. Ochsner J. 2013;13:400-406.
  2. Frankel AS, Leonard MW, Denham CR. Fair and just culture, team behavior, and leadership engagement: The tools to achieve high reliability. Health Serv Res. 2006;41(4 Pt 2):1690-1709.
  3. Meadows S, Baker K, Butler J. The incident decision tree: Guidelines for action following patient safety incidents. In: Henriksen K, Battles JB, Marks ES, et al., editors. Advances in Patient Safety: From Research to Implementation. 2005

This article originally appeared on Renal and Urology News