Creating a “just culture”: More work to be done

Abstract

A fundamental lesson for healthcare leaders is that individual providers are not solely to blame for medical errors. This dictum is at the core of the 2000 Institute of Medicine report To Err is Human. The report asserts that “the problem is not bad people in health care—it is that good people are working in bad systems that need to be made safer.” This message charted a new course of action for healthcare organizations seeking to improve patient safety. The aim was to replace the prevailing culture of blame—in which individuals are singled out, faulted, and often punished for errors— with one that is blame-free and non-punitive. James Reason described “vulnerable system syndrome,” a condition that afflicts organizations that blame front-line workers and deny the role of systemic error in creating vulnerabilities. This inevitably leads to denial by individuals and reduces the ability of organizations to learn from their mistakes. A blame-free culture is one in which individuals feel able to report errors without fear of punishment. This permits more reporting of harmful incidents and nearmisses, encourages more collaboration across disciplines, and allows a focus on finding systemic solutions. Thought leaders began calling for a blame-free approach to handling mistakes in medicine. Others justifiably pointed out the conflict between instituting a blame-free culture in the health system and the need in some cases to attribute responsibility. They worried that a “no blame” stance seems to dismiss any form of accountability for individuals. Some even argued for the benefits of punishment.6–8 Reason developed a theory of a “just culture” as a component of a culture of safety, which he thought was required to build trust and allow reporting. In 2001, David Marx expanded the concept of “just culture” to one “that is in between a blame-free culture and a punitive culture...one that encourages people to raise their hands and say they made a mistake, yet still holds them accountable if they choose behavior that knowingly puts someone at risk.” In this framework, individuals are held accountable for reckless or willful misconduct. Human error may result in an individual being offered additional training or education. However, willful misconduct may result in disciplinary action including termination of employment, even if no harm resulted. Just culture has been embraced as a mechanism for hospital administrators to assign worker accountability for medical errors and adverse events. In practice, is it an improvement on the blame-free approach? In general, it takes a long time, perhaps decades, for new ideas to catch on in medicine. Nearly 25 years after To Err is Human, most healthcare professionals understand the importance of patient safety and the system causation of medical errors and patient harm. The idea of a blame-free, non-punitive approach to handling medical errors is relatively easy to comprehend and is reassuring to healthcare workers. When it comes to just culture, the algorithm for drawing the line between acts that are blameworthy and those that are blameless is more complex. It can be difficult to determine if an individual’s actions were risky, reckless, or even intentional. The determination requires subjective judgments aboutwhat is a foreseeable risk, what is reasonable, and what is prudent. There is also evidence suggesting that workers from different disciplines vary in their perceptions. A review of strategies for implementingjustculturesuggests that training iscritical for implementation and sustainability. Training should define just culture, explain why it is important for patient safety, characterize types of behaviors and remedies, and provide examples of appropriate responses to errors. Training should include bothmandatory sessions and ongoing activities. Resources have been developed to promote the approach. For example, the U.S. Veterans Health Administration developed the Just Culture Decision Support Tool to help leaders respond to errors in a way that is consistent with just culture principles. However, this level of effort is greater than required to understand blame-free. If just culture is notwell understood, its applicationmay look a lot likeblame tohealthcareworkers.Badnews spreadsquickly in hospitals, and a single case inwhich aworker appears to have been punished unfairly is likely to have a chilling effect on the willingness of others to talk about mistakes. Right now, signs indicate that blame culture is still too prevalent in healthcare. A systematic review of patient safety culture surveys from over 750,000 professionals from around the world found that less than a third reported that the response to errors at their hospital was non-punitive. These numbers have been slowly getting better year over year. However, under-reporting remains a giant obstacle to improving safety. A systematic review of barriers to reporting found fear of consequences was the most commonly (63%) reported barrier. This may help to explain the persistence of preventable patient harm. A World Health Organization report to the World Health Assembly in 2019 stated: “The reporting environment should be open, fair, blame-free and non-punitive to encourage health care professionals to report and learn from incidents.” Editorial