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Published On June 10, 2015

POLICY

Defined: Just Culture

A new organizational approach views medical errors in a whole new light.

just culture n: An approach to assigning responsibility for medical errors.  It considers the actions of individuals as well as the systems in which they operate.

Doctors and nurses make mistakes, and those mistakes can have heartbreaking consequences. When lives are lost, fingers will point,  historically in the direction of the health care workers themselves. But the real object of blame is often more complicated, something underlined in a landmark Institute of Medicine report (To Err Is Human, 1999), which argued that faulty organizational processes may be as much or more to blame than a lone clinician.

The term “just culture” describes an organization that understands this bigger picture and works to place blame fairly. In the wake of an error, a just culture would first look at the participant’s intentions. Was it the result of a mindless lapse, like grabbing the wrong vial? Or was this a deliberate choice to violate hospital protocol? Misjudging a risk might fall somewhere in the middle. Attention then turns to the hospital’s system for protecting against such errors. Did the doctor or nurse have  adequate training? Had fail-safe procedures been put in place? 

This more “just” understanding of an error  can make sure that corrective actions are  directed effectively. The principles have been used in aviation, the military and other industries in which human error is likely to have major consequences—and where it’s critically important  to keep errors from happening again.