An Assessment of the Impact of Just Culture on Quality and Safety in US Hospitals

Edwards, Marc T.

doi:10.1177/1062860618768057

Cited by 27 publications

(27 citation statements)

References 23 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…Although the evolution of Western thought regarding patient safety to the present organizational emphasis on just culture has its advocates, it also has its critics. Edwards assessed the effect of the shift toward a just culture on meaningful change in the reporting of errors since the publication of To Err Is Human . Although he found that most health care organizations are adopting a just culture, the statistics from his survey failed to show significant improvement in self‐reporting, which is a key factor in developing the learning environment considered foundational for a just culture .…”

Section: Discussionmentioning

confidence: 99%

“…Edwards assessed the effect of the shift toward a just culture on meaningful change in the reporting of errors since the publication of To Err Is Human . Although he found that most health care organizations are adopting a just culture, the statistics from his survey failed to show significant improvement in self‐reporting, which is a key factor in developing the learning environment considered foundational for a just culture . Determining whether the shift toward just culture has improved safety in health care or is still a work in progress is outside the scope of this article.…”

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Using Good Catches to Promote a Just Culture and Perioperative Patient Safety

Monahan¹

2018

AORN Journal

View full text Add to dashboard Cite

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Using Good Catches to Promote a Just Culture and Perioperative Patient Safety

Monahan¹

2018

AORN Journal

View full text Add to dashboard Cite

“…Following the full‐text review, the dissertation 9 and one of the empirical reports 10 were eliminated from data evaluation because they did not meet inclusion criteria. Of the four remaining empirical reports, there was no evidence higher than Level VI, using Melnyk's hierarchy of levels of evidence 11 .…”

Section: Methodsmentioning

confidence: 99%

Just culture in healthcare: An integrative review

Barkell

Snyder

2020

Nursing Forum

View full text Add to dashboard Cite

Background In spite of two decades of the patient safety movement in the United States, healthcare safety remains a significant problem. The paucity of empirical literature related to Just Culture in healthcare indicates a need for this concept to be examined and operationalized. Purpose The purpose was to appraise the literature regarding the use and application of Just Culture in healthcare. Methods Using Whittemore and Knafl's framework for integrative reviews, a review of the literature was conducted using Cumulative Index to Nursing and Allied Health Literature, PubMed, PsychInfo, and Cochrane Review to identify peer‐reviewed literature published between 2010 and 2020. The following search terms were used: “Just Culture” AND “healthcare system” OR “health care” OR “healthcare.” Results After screening for inclusion and exclusion criteria, a set of 10 articles were included in the review. Four main themes were identified: Error Management, Balance, Leadership and Staff, and Systems Leadership for Change. Conclusion There is a paucity of empirical research and quality improvement projects focusing on Just Culture. The themes identified in this integrative review provide the direction and focus for additional research and quality improvement efforts that will promote the adoption of Just Culture and improvement in patient safety.

show abstract

“…However, several authors have raised concerns around just culture, citing limited evidence that it has led to improvements in reporting or reductions of the blame culture (Edwards, 2018). Von Thaden et al (2006) and Dekker and Hugh (2010) express caution about the ability to draw a line between blameworthy and blameless acts, and about who should draw that line.…”

Section: ‘Inconvenient Truths’ In Suicide Preventionmentioning

confidence: 99%

Inconvenient truths in suicide prevention: Why a Restorative Just Culture should be implemented alongside a Zero Suicide Framework

Turner

Stapelberg

Sveticic

et al. 2020

Aust N Z J Psychiatry

View full text Add to dashboard Cite

Objective: The prevailing paradigm in suicide prevention continues to contribute to the nihilism regarding the ability to prevent suicides in healthcare settings and a sense of blame following adverse incidents. In this paper, these issues are discussed through the lens of clinicians’ experiences as second victims following a loss of a consumer to suicide, and the lens of health care organisations. Method: We discuss challenges related to the fallacy of risk prediction (erroneous belief that risk screening can be used to predict risk or allocate resources), and incident reviews that maintain a retrospective linear focus on errors and are highly influenced by hindsight and outcome biases. Results: An argument that a Restorative Just Culture should be implemented alongside a Zero Suicide Framework is developed. Conclusions: The current use of algorithms to determine culpability following adverse incidents, and a linear approach to learning ignores the complexity of the healthcare settings and can have devastating effects on staff and the broader healthcare community. These issues represent ‘inconvenient truths’ that must be identified, reconciled and integrated into our future pathways towards reducing suicides in health care. The introduction of Zero Suicide Framework can support the much-needed transition from relying on a retrospective focus on errors (Safety I) to a more prospective focus which acknowledges the complexities of healthcare (Safety II), when based on the Restorative Just Culture principles. Restorative Just Culture replaces backward-looking accountability with a focus on the hurts, needs and obligations of all who are affected by the event. In this paper, we argue that the implementation of Zero Suicide Framework may be compromised if not supported by a substantial workplace cultural change. The process of responding to critical incidents implemented at the Gold Coast Mental Health and Specialist Services is provided as an example of a successful implementation of Restorative Just Culture–based principles that has achieved a culture change required to support learning, improving and healing for our consumers, their families, our staff and broader communities.

show abstract

An Assessment of the Impact of Just Culture on Quality and Safety in US Hospitals

Cited by 27 publications

References 23 publications

Using Good Catches to Promote a Just Culture and Perioperative Patient Safety

Using Good Catches to Promote a Just Culture and Perioperative Patient Safety

Just culture in healthcare: An integrative review

Inconvenient truths in suicide prevention: Why a Restorative Just Culture should be implemented alongside a Zero Suicide Framework

Contact Info

Product

Resources

About