We all make mistakes. Human error is a part of life. In many everyday situations, each of us makes errors, and most of the time, these errors bear no significant consequences for our lives or the lives of others. You accidentally grab one brown shoe and one black one out of your closet. Once you realize your mistake, the search for matching shoes might cause you a slight delay, but overall no harm is done. However, if you’re a healthcare provider, and you mistake one medication for another, the consequences could be much more serious.
Making Mistakes in a Learning Culture
Historically, the healthcare field has been marked by a punitive mindset, such that all mistakes, even those that bore no ill consequences, were reprimanded. This punitive attitude, which initially developed from the desire of healthcare organizations to safeguard themselves against all potential damages, eventually grew into an atmosphere that deterred even minor mistakes from being reported out of fear of punishment. This kind of atmosphere stifles constructive learning and tends to make providers feel unsupported by the healthcare systems in which they work.
A healthcare learning culture is the opposite. A healthcare learning culture takes everyday occurrences, even mistakes, and uses them so that both organizations and providers can grow in knowledge, performance, and competence. A learning culture engenders a just culture, and a just culture fortifies a learning culture. Just culture seeks to create and reinforce a learning culture by providing a framework for managing mistakes and actions. Just culture acknowledges that all people, including system designers, make mistakes.
So, for the healthcare provider who mistook one medication for another, a just culture promotes an environment where the provider who made the error should not fear to come forward. A just culture investigates to see if the error was part of a system failure such that any provider in a similar situation would have made the same mistake.
A just culture, then, differentiates among unintentional human errors, system errors, mistakes made because of poor decision making, mistakes made because of disregard for procedures, and deliberate actions intended to be harmful. This differentiation helps determine the level of accountability and allows for a response on the part of the organization that is fitting and fair for the mistake maker.
Just culture is founded in the belief that all stakeholders—from healthcare providers to business leaders—are responsible for the quality and safety of services. It demands that providers adhere thoughtfully and safely to clinical standards; furthermore, it expects that even minor errors are reported so that broader learning needs and system failures can be identified. In a just culture, errors become opportunities for the organization and all its providers, not just those who make mistakes, to learn and improve, which greatly reduces the chance that an error will be repeated.
Just culture shifts the focus of quality improvement from punishment and faultfinding to the management of behavioral choices in the context of the systems in which providers work. Medcor has found that embracing a learning culture and a just culture increases provider job satisfaction and adds significant value to our quality improvement processes. Just culture treats our advocates with fairness and respect and makes our leadership consider how we can improve our systems to promote the best outcomes for our employees, patients, and clients.
Interested in working for a healthcare company with a just culture? Apply now.
Philip G. Boysen II, “Just Culture: A Foundation for Balanced Accountability and Patient Safety,” The Ochsner Journal 13, (2013): 400–406.
David Marx, “Patient Safety and the ‘Just Culture’: A Primer For Health Care Executives,” David Marx Consulting, (2001).