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Just culture: Balanced Accountability for Systems and Individuals During Safety Event Reviews

Author: Hemangi Shukla, DO

Editor: Timothy Klatt, MD

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In 1999, the Institute of Medicine (now known as the National Academy of Medicine) estimated that preventable medical errors caused 98,000 hospital deaths annually and called on health care organizations to develop a “culture of safety.” Traditionally, responses to medical errors or adverse outcomes have been punitive, blaming individuals for errors and neglecting relevant system failures beyond their control, setting them up to fail. These responses disincentivize error reporting and perpetuate risk-laden system designs. When solely individuals are held accountable, risk remains unmitigated. 

In 2001, the phrase just culture was first applied to health care. Just culture describes a system of shared accountability in which organizations are held accountable for their systems of care delivery and for responding to their employees’ behavior in a fair and just manner. A just culture shifts the focus of the analysis to the systems of care delivery and evaluates each involved individual’s behavioral choices.

Patient safety is improved with the panoramic lens of a just culture, where employees actively look for and report harm events and near misses. Within a just culture, employees trust that they will not be shamed or blamed. Events can then be analyzed, and improvements can be implemented to make harm, including individual errors, less likely.  

While a just culture moves away from a culture of blame by identifying system vulnerabilities, it also holds individuals responsible for their actions in care delivery. Errors are classified as resulting from systems weaknesses or individual behavior. Behavioral issues are further stratified into categories to inform the response. 

Systems Error
Systems errors are defined as events where others in the same profession having comparable knowledge, skills, and experience would have acted the same under similar circumstances. Examples include cases in which deficiencies of training or supervision contributed. The recommended response is formal systems analysis and redesign to make errors less likely. For example, a clinic routinely books attending physicians to see patients while precepting residents, and a patient is sent home who later presents with hemolysis, elevated liver enzymes, and low platelets (HELLP syndrome) but had mild-range blood pressure missed in the clinic.

Reckless Behavior
Reckless behavior is defined as a choice to consciously disregard substantial and unjustifiable risk. This includes cases where individuals acted with the intent of causing harm. Responses to consider include corrective action, referral to a professional licensing board, and/or involving law enforcement. Within a just culture, reckless behavior is unacceptable. An example of reckless behavior would be a physician performing an elective induction of labor before 37 weeks to avoid conflicts with other engagements.

At-Risk Behavior
At-risk behavior is defined as an intentional violation of known policy or procedure that makes a system vulnerable with an increase in risk. However, the risk is either unrecognized by the individual or erroneously believed to be justified. The recommended approach is to coach. An example of at-risk behavior would be a physician automatically clicking “reviewed” on an electronic medical record early-sepsis warning because a laboring patient “is never actually septic when that warning shows,” and the patient progresses to septic shock.

Unintended Human Error
Unintended human errors include mistakes or lapses. These errors are unintentional. The recommended approach is to console and correct. An example of an unintended error would be a physician misreading urine culture sensitivities and prescribing an ineffective antibiotic and the patient subsequently develops pyelonephritis.


Further Reading:

Institute of Medicine (US) Committee on Quality of Health Care in America, Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human: Building a Safer Health System. National Academies Press; 2000.

Marx DA. Patient Safety and the “Just Culture:” a Primer for Health Care Executives. Columbia University; 2001.

ACOG Committee Opinion No. 447: Patient safety in obstetrics and gynecology. Obstet Gynecol. 2009 Dec;114(6):1424-1427. doi: 10.1097/AOG.0b013e3181c6f90e. PMID: 20134298.


Final editing of initial publication performed by The Medical Pen, LLC.

Initial publication May 2023


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