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Interested in implementing just culture strategies in your organization? Below is a handy checklist of tips that are sure to assist your organization in becoming a fair, accusation-free environment.


[check mark] Avoid blame.


[check mark] Work on fixing the system, not the person.


[check mark] Steer clear of complexity in process design.


[check mark] Include redundancy, especially in high-risk procedures (checks and rechecks).


[check mark] Make expectations clear.


[check mark] Work to mitigate risk, such as fatigue, distractions, overload, and complexity.


[check mark] Always involve staff before making changes.


[check mark] Focus on process and behaviors, not on the outcome.


[check mark] Use coaching to correct knowledge deficit and risky behaviors.


[check mark] Use discipline for reckless behavior that puts patients at risk.


[check mark] Address skill issues-competency isn't optional.


[check mark] Use errors as a learning experience.


[check mark] Ensure solid orientation for new staff.


[check mark] Make sure that all staff members are up-to-date on practice issues and improvements.


[check mark] Be vigilant for system weaknesses.


[check mark] Proactively address system short- and long-term solutions.


[check mark] Remember that neither people nor systems are perfect.


[check mark] Talk about patient safety at every staff meeting.


[check mark] Staff "right" and provide contingency safety help if staffing isn't optimal.


[check mark] Consider why rules may be broken-maybe they're bad rules or there's pressure to work around the rule.


[check mark] Measure it.


[check mark] Emphasize that safety is everyone's job.1,2





1. The Just Culture Community. Available at: Accessed August 2, 2007. [Context Link]


2. Just Culture Toolkit. The Risk Management and Patient Safety Institute. 2005. [Context Link]