Patient Safety and the Just Culture

Marx, David

doi:10.1016/j.ogc.2019.01.003

Cited by 59 publications

(80 citation statements)

References 1 publication

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“…Upon full‐text review, one of these articles 19 was excluded because it was determined to be a commentary. The remaining four theoretical articles 20–23 were retained for a total of 10 records for data analysis. This is shown in Figure 1.…”

Section: Methodsmentioning

confidence: 99%

Just culture in healthcare: An integrative review

Barkell

Snyder

2020

Nursing Forum

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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.

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Section: Methodsmentioning

confidence: 99%

Just culture in healthcare: An integrative review

Barkell

Snyder

2020

Nursing Forum

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“…Outcome bias, where we allow the outcome of an event to influence our response to it, also represents a barrier to safety and a sense of justice. As noted by Marx (2019), there is a need to understand the actions of staff, rather than the outcomes they produce, as reacting to the severity of the outcome may simply punish the unlucky. Our current review systems revolve around outcome bias, focusing predominantly on events with the worst outcomes.…”

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

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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.

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“…Just culture offers a model for creating positive workplaces in health care settings 6,7 by balancing "the need for an open and honest reporting environment with the end of a quality learning environment and culture." 7 Its premises echo conclusions from the Institute of Medicine's 1999 report, To Err is Human: Building a Safer Health System, 8 which found that most medical errors arise from "faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them" rather than from reckless actions by individuals working within those systems.…”

Section: Just Culturementioning

confidence: 99%

“…A just culture framework endeavors to balance 3 basic duties-to avoid causing unjustified risk or harm, to produce desired outcomes, and to follow procedural rules-against shared organizational and individual values of dignity, safety, equity, cost, and effectiveness. 6,7 Under the just culture framework, medical mistakes, such as medication errors, can be classified as simple human error (eg, unintentional errors or lapses), as risky behaviors (ie, "a conscious drift" toward actions in which the risks taken are unforeseen or mistakenly believed to be justified), or as recklessness, defined as willful disregard of unjustified risks. 7 Recommended remedies for these mistakes are, respectively, consolation, coaching to understand risks, and punishment, where corrective responses are based upon clinician behaviors rather than patient outcomes.…”

Section: Just Culturementioning

confidence: 99%

Why Accountability Sharing in Health Care Organizational Cultures Means Patients Are Probably Safer

Eng

Schweikart

2020

AMA Journal of Ethics

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Because human errors should be regarded as expected events, health care organizations should routinize processes aimed at human error prevention, limit negative consequences when human errors do occur, and support and educate those who have erred. A just culture perspective suggests that responding punitively to those who err should be reserved for those who have willfully and irremediably caused harm, because punishment creates blame-based workplace cultures that deter error reporting, which makes patients less safe.

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Patient Safety and the Just Culture

Cited by 59 publications

References 1 publication

Just culture in healthcare: An integrative review

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

Why Accountability Sharing in Health Care Organizational Cultures Means Patients Are Probably Safer

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