Just Culture

Health care is a high-risk industry and all employees must be actively engaged in the creation of safety in these complex systems.

An important component in the creation of safer systems is the active engagement of all employees in reporting errors and hazards. Approaches that focus on punishing individuals instead of changing systems provide strong incentives for people to report only those errors they cannot hide. A punitive approach shuts off the information that is needed to identify faulty systems and create safer ones. In a punitive system, no one learns from their mistakes.

A just culture is an alternative to an overly punitive system and addresses the weaknesses of a solely blame-free approach. It acknowledges that competent professionals make mistakes, no system can be designed to produce perfect results, and even competent professionals will develop unhealthy norms such as shortcuts and routine rule violations. A just culture, however, has zero tolerance for reckless behaviour.


What is a Just Culture?

Principles of a Just Culture

  • A just culture refers to a model that supports organizational values and shared accountability. It holds organizations accountable for the systems they design and for how they respond to staff behaviours fairly and justly. It holds staff accountable for the quality of their choices and for reporting both their errors and system vulnerabilities.
  • A just culture emphasizes learning and accountability over blame and punishment. It recognizes that forbidding errors cannot prevent them from happening. The goal is to learn from errors and implement safeguards to reduce the opportunity for future errors. Incidents that do not result in harm are viewed as free lessons and additional opportunities to create safer systems. 
  • A just culture recognizes that everyone throughout the organization is aware that medical errors are inevitable and can result in patient harm. Everyone in the organization assumes the responsibility to report all errors and unintended events, even though the events may not result in patient injury.

Just Culture Algorithm

Algorithm To Guide Decision Making