Practice Matters
Just culture promotes a
THE HUMAN SIDE OF P AT I E N T S A F E T Y
partnership for patient safety
By Susan Tocco, MSN, CNS, CNRN, CCNS, and Allison Blum, MHA
Editor’s note: This is first in a series of articles exploring
the human side of patient safety.
HISTORICALLY, hospitals have operated under the as-
sumption that health care involves the isolated work of
a sole expert clinician with an individual patient. So
when an error occurred, the clinician was blamed and
faced punitive action. As long ago as 2100 BC, the
Code of Hammurabi called for amputation of a sur-
geon’s hands if he committed a surgical error.
In 1999, the Institute of Medicine (IOM) report “To
Err Is Human: Building a Safer Health System” chal-
lenged the healthcare industry to recognize how sys-
temic problems in a healthcare organization can con-
tribute to errors and to migrate away from blaming
individual clinicians. Moving away from a culture of
blame will empower us to look at events comprehen-
sively, identify the true causes of an error, and take
appropriate corrective action.
So how do we transform our systems and work en-
vironments? By understanding how the “blame culture”
emerged, acknowledging it isn’t working, and moving
toward just culture, which encourages open reporting
of errors, recognizes errors may be systemic rather than
personal failures, and focuses on determining the root
of the problem when events such as errors and near-
misses occur.
How the blame culture emerged
In 1917, the American College of Surgeons (ACS) devel-
oped the Hospital Standardization Program (HSP) in an
attempt to standardize medical education and physician
competency. Peer review was used to assess physician
quality. Accounts from this time suggest this method
initially succeeded in improving hospital standards. But
in the 1950s, the peer-review model morphed into a
punitive, fear-based model that led to sanctions and
even imprisonment for physicians. This change didn’t
improve the quality of care. In essence, HSP enforced
minimal practice standards but did nothing to promote
or inspire excellence.
Hospitals haven’t deliberately chosen a blame cul-
ture. Compliance-driven, bureaucratic management
styles that demand personal accountability for systemic
problems have enabled the blame culture to flourish.
The traditional process for conducting root-cause ana-
16 American Nurse Today Volume 8, Number 5
In just culture, leaders and
frontline staff share
accountability for the quality
and safety of patient care.
lyses (RCA) also contributes. When a sentinel event
occurs, regulatory agencies require an RCA to be per-
formed and an action plan to be submitted promptly
for review. (A sentinel event is an unexpected event
involving death or serious physical or psychological in-
jury or the risk of death or serious injury).
Imagine you’re a nurse manager attending an RCA
meeting for a medication error involving one of your
staff nurses. It’s clear that problems with the electronic
medical record contributed significantly to the error. Yet
you’re told repeatedly there’s no easy fix for the prob-
lem. In fact, it could take up to 9 months to resolve be-
cause the hospital has to wait for a vendor’s software
upgrade. You’ve learned that if you acknowledge the
true systemic issue, you’ll be held accountable for the
timely action plan, which you can’t control. You feel re-
sponsible that your staff nurse is deemed at fault when
you knew she was operating in an unsafe system. In the
end, your personal accountability for the action plan
leads you to “fix” the error on paper by reeducating
your staff nurses on the five rights of medication admin-
istration and counseling the specific nurse in the context
of progressive discipline. With progressive discipline,
an employee receives feedback regarding work perform-
ance; the first occurrence of an error results in verbal
counseling, the second leads to written counseling, and
the third may progress to suspension. Meanwhile, the
systemic problem persists, continuing to put patients at
risk for harm and staff nurses at risk for blame.
Recognizing the blame culture isn’t working
Hospitals are accountable for improving the safety and
quality of patient care. But to improve care, we need
to have a clear understanding of the problems that af-
fect safety and quality. Most likely, hospital administra-
tors are aware of some of the problems—but frontline
staff know about every problem. How likely are they
to share this information with managers and adminis-
trators if they face retribution?
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 Evidence suggests staff may feel more uncomfortable
with the blame culture than we realize. The Hospital
Survey on Patient Safety Culture conducted by the
Agency for Healthcare Research and Quality is a valid,
reliable survey used to assess patient safety-culture per-
ceptions among healthcare leaders and staff. Research
on this tool shows frontline staff perceptions of safety
most accurately reflect the organization’s actual safety
performance. In the 2009 survey, results for the item
“Staff feel free to question the decision or actions of
those with more authority” revealed 68% of leaders
agreed or strongly agreed with this statement, com-
pared to only 45% of staff.
Moving toward just culture
The IOM report underscores the need to move away
from a blame culture to better understand the complex
causes of errors. Quality and safety leaders endorse just
culture adoption as a way to analyze the actions of clini-
cians involved in errors and to recognize the contribu-
tion of systemic factors. Just culture has a simple model
for accountability for errors, which asks four questions:
1. Was the clinician knowingly impaired?
2. Did the clinician consciously engage in an unsafe act?
3. Did the clinician make a mistake that three other
clinicians with similar experience are likely to make
under the same circumstances? (substitution test)
4. Does the clinician have a history of committing un-
safe acts?
This model doesn’t absolve the clinician of personal
responsibility for the error. Just culture isn’t blame-free;
for example, it would hold accountable and call for
discipline of a nurse who repeatedly and consciously
disregarded a policy calling for independent double veri-
fication of blood products. But if a nurse makes a med-
ication error that three other nurses with similar experi-
ence could make, systemic factors clearly contributed to
the error. Perhaps the hospital’s barcoding system is un-
reliable. Maybe a medication protocol is unclear and
hard to follow or the medication comes in different con-
centrations not clearly differentiated on the vials.
Performing the substitution test forces recognition and
analysis of these issues. In a mature just culture where
just-culture values have become entrenched, the ques-
tion isn’t “Who did it?” but “How could it happen?” If an
RCA stops at “Who did it?” and blames the individual,
systemic contributions go unrecognized, the error will
likely recur, and more patients will be placed at risk.
Partnership of accountability
In a just culture, leadership and frontline staff share ac-
countability for safety. Staff are responsible for recogniz-
ing and reporting errors and error-prone systems and
openly discussing them with managers and peers. Lead-
ers are charged with creating an environment where
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Promoting just culture in your
practice environment
You can take the following actions to promote just culture
in your work environment:
• Report errors, near-misses, and other events to your
manager and colleagues.
• Encourage colleagues to report their own events.
• Discuss with colleagues what can be done to prevent fu-
ture events. For instance, they could share them infor-
mally in conversations with peers and share them in staff
meetings and unit practice council meetings.
• Partner with your manager in communicating your unit’s
experiences to the nursing practice council or quality
council. This promotes learning from these events, which
translates to safer care.
• Help colleagues “connect the dots” by linking changes in
practice to learning from events.
staff are comfortable disclosing actual and potential er-
rors. Leaders promote organizational learning from these
events and take actions to ensure that nurses practice in
a safe environment. To promote upward reporting of
events, leaders ensure that reporting won’t place the re-
porter at risk for punishment. What’s more, staff believe
their concerns are heard and real action is taken when
necessary, making their disclosures worthwhile.
The partnership for patient safety is interdependent.
Staff need their leaders to ensure a safe practice environ-
ment, and leaders depend on staff to tell them about
systemic problems so they can address these. (See Pro-
moting just culture in your practice environment.)
In many hospitals, shared leadership in nursing al-
ready is embedded as an integral component of the
model for the Magnet Recognition Program®. This model
was introduced largely to promote exemplary nursing-
sensitive outcomes. Implementing a just culture furthers
this partnership. In the new paradigm, patient safety be-
comes a powerful new nursing-sensitive outcome. O
Visit www.AmericanNurseToday.com/Archives/aspx for a complete list
of selected references.
Selected references
Bashaw ES. Fusing Magnet® and just culture. Am Nurs Today. 2011;
6(9):42-5.
Berhans LD. Just culture and nursing regulation: learning to improve
patient safety. J Nurs Reg. 2012;2(4):43-9.
Institute of Medicine. To Err Is Human: Building a Safer Health Sys-
tem. Washington, DC: National Academies Press; 1999.
Khatri N, Brown GD, Hicks LL. From a blame culture to a just culture
in health care. Health Care Manage Rev. 2009;34(4):312-22.
Lazarus I. On the road to find out...transparency and just culture offer
significant return on investment. J Healthc Manag. 2011;56(4):223-7.
The authors work at Orlando Health in Orlando, Florida. Susan Tocco is the director
of Patient Safety and Transformation. Allison Blum is an administrative fellow.
May 2013 American Nurse Today 17