1. Lockhart, Lisa MHA, MSN, RN, NE-BC

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Q: What's just culture?

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A: In a just culture, accountability and quality are achieved by improving processes and systems in the work environment. The goal is the development of an organizational culture that promotes and exhibits a quality learning environment as a responsibility to both employees and patients. Every employee is held accountable for patient safety and the quality of his or her practice choices; however, the focus is on systems design rather than blame for errors.


A just culture must include the creation of an open, fair, and learning environment; the design of safe systems; and the management of behavioral choices. To accomplish this, all layers of the organization must be engaged in open communication and willing to shed any preconceived notions of error reporting. For many organizations, the largest barrier is the establishment of trust, which is vital in the reporting of errors and the analysis of processes.


One of the first steps in establishing trust is setting organizational rules and practice standards that are applicable to all layers of the organization, based on mutual values and a communicated, enforced mission statement. This means that every member of the organization knows the strategic plan and what's expected. The key is to manage these expectations, along with behaviors.


Three categories of behavior are human errors, at-risk behaviors, and reckless behaviors. Most errors are the result of human error due to poor processes, programs, education, environmental issues, or situations. These are managed by correcting the cause, looking at the process, and fixing the deviation-not the human.


At-risk behaviors occur when it's easier to make the wrong choice. Examples include working around the medication administration policy by pulling a medication under another patients name in an emergency or failing to scan a medication when the scanner won't "accept" the patient's band, but delivering the medication anyway. The way to address this once identified is to make the correct choice more rewarding, such as by recognizing scanning compliance or setting up medication dispensing systems with medications that can be placed in override in emergency situations so that the correct patient is identified.


Reckless behaviors are addressed by correcting the person. When a nurse intentionally disregards medication administration policies and deliberately foregoes the safety mechanisms, it's reckless behavior by choice. Such behavior should be addressed by progressive discipline that begins with re-education on policies and procedures, along with why they're in place. Continued failure to follow policies and procedures places patients, staff, and the organization at risk.


A just culture in which employees aren't afraid to report errors is a highly successful way to manage safety, increase staff and patient satisfaction, and improve outcomes. Success is achieved through good communication, effective management of resources, and the development of a process for ensuring the safety of patients and employees.