6. An Introduction to Just Culture
The single greatest impediment to error
prevention in the medical industry is
“that we punish people for making mistakes”
Dr. Lucian Leape
Professor, Harvard School of Public Health
Testimony before Congress on
Health Care Quality Improvement
7. Safe Culture
• The first and possibly most important step in promoting a safe
culture is the establishment of justice.
– Just Culture
– A system of shared accountability
– The organization is responsible for safe system and process design
– And employees are responsible for safe choices and behaviors
• This shifts an organization away from a “blame” culture.
• Why?
• Because to design safety, the organization needs feedback from
users (employees).
• To give feedback, employees need trust.
• An organization can establish this trust through a consistent and fair
approach to managing employee behaviors.
9. Establishment of a Just Culture
• Outcome Engineering of Plato, Texas defines these three
behaviors as follows:
• Human Error:
– An inadvertent action; inadvertently doing other that what
should have been done; slip, lapse, mistake.
– Product of current system design and behavioral choices
• At‐Risk Behavior:
– A behavioral choice that increases risk where risk is not
recognized, or is mistakenly believed to be justified.
– A choice, risk believed insignificant or justified
• Reckless Behavior:
– A behavioral choice to consciously disregard a substantial and
unjustifiable risk.
11. Establishment of a Just Culture
• At‐Risk Behavior:
– A behavioral choice that increases risk where risk is
not recognized, or is mistakenly believed to be
justified.
– A choice, risk believed insignificant or justified
• Manage through:
– Removing incentives for at‐risk behaviors
– Creating incentives for healthy behaviors
– Increasing situational awareness
• Coach