How a "Just Culture" Can Improve Safety in Health Care

Katie Brewer, MSN, RN


Am Nurs Journal. 2011;6(6) 

In This Article

The Blame Game

But one of the critical pieces of these recent events is that while blaring headlines of sleeping air traffic controllers led to calls for immediate firings, this is part of a "blame culture." It may be instinctive to seek immediate punishment, but this paradigm is actually counteractive to preventing these types of mishaps. Nurses may have experienced this knee-jerk reaction in their practices, such as a nurse being immediately disciplined for a medication error.

In place of this, ANA is among the advocates for the use of the "just culture" concept. This concept (which is, ironically, most widely used in the aviation industry) recognizes that human error and faulty systems can cause a mistake, and encourages an investigation of what led to the error instead of an immediate rush to blame a person. Through this process, systems that may perpetrate or perpetuate errors can be fixed. It gives workers the opportunity to feel more at ease reporting problems, and a sense of accountability for system improvement.

While it discourages blame, it is not a "no-fault" system. It does not tolerate malicious or purposefully harmful behavior, and supports disciplinary actions to persons that engage in such behavior. But it supports coaching and education if the mistake was inadvertent, or occurred in a system that was not supportive of safety. Mandatory overtime or insufficient rest breaks on overnight shifts leading to fatigue might be such systems flaws.

The FAA has policies that use of just culture, including its use in preventing fatigue-related incidents. The famous pilot hero Captain Chesley B. "Sully" Sullenberger, in his remarks at a 2010 FAA safety symposium, advocated for the use of just culture in the aviation industry.

"The emphasis on process control and continuous improvement through reporting and learning in a just culture improve quality as well as safety and provide the operator with business benefits," Sullenberger said. "Just as in health care, quality and safety improve the outcome and the bottom line."

Sullenberger's comments point to the uncanny linkages between nursing and aviation. Both feature a high-stress, 24/7 operational environment where there are serious implications on safety if there is an error. Fatigue is a factor – whether it is brought on by the worker themselves (e.g. squeezing in overtime shifts or working a daunting schedule to maximize time off), or the system (e.g. requiring overtime or insufficient staffing). If an error happens, there can be a rush to blame and punish. But a just culture environment can help get the root of the problem, whether it is the worker willfully contributing to the error, or the system providing inadequate support to the worker's needs. This can help workers feel empowered to solve problems and prevent errors, instead of being afraid.

And in both situations - aviation and nursing - professionalism, advocacy, and policy change can help support safe and efficient environments.


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