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Just Culture: A Foundation for Balanced Accountability
and Patient Safety
Philip G. Boysen II, MD, MBA, FACP, FCCP, FCCM
Department of Anesthesiology, Ochsner Clinic Foundation, New Orleans, LA, Emeritus Professor, University of North Carolina
at Chapel Hill, Chapel Hill, NC
ABSTRACT
Background: The framework of a just culture ensures balanced
accountability for both individuals and the organization
responsible for designing and improving systems in the
workplace. Engineering principles and human factors analysis
influence the design of these systems so they are safe and
reliable.
Methods: Approaches for improving patient safety introduced
here are (1) analysis of error, (2) specific tools to enhance
safety, and (3) outcome engineering.
Conclusion: The just culture is a learning culture that is
constantly improving and oriented toward patient safety.
INTRODUCTION
People make errors. Errors can cause accidents.
In healthcare, errors and accidents result in morbidity
and adverse outcomes and sometimes in mortality.
One organizational approach has been to seek
out errors and identify the responsible individual.
Individual punishment follows. This punitive approach
does not solve the problem. People function within
systems designed by an organization. An individual
may be at fault, but frequently the system is also at
fault. Punishing people without changing the system
only perpetuates the problem rather than solving it.
A patient care system is obligated to collect
productive investigative data that can be analyzed
and acted upon to improve patient safety. This
process is not possible unless members of the
organization remain vigilant and mindful and maintain
continuous surveillance. Similarly, people within the
organization must believe that they are obligated to
report errors. However, medical institutions cannot
afford a blame-free culture: Some errors do warrant
disciplinary action. Finding a balance between the
extremes of punishment and blamelessness is the
goal of developing a just culture.1
JUST CULTURE: CONCEPT AND
PHILOSOPHY
A just culture balances the need for an open and
honest reporting environment with the end of a quality
learning environment and culture. While the organization
has a duty and responsibility to employees
(and ultimately to patients), all employees are held
responsible for the quality of their choices. Just
culture requires a change in focus from errors and
outcomes to system design and management of the
behavioral choices of all employees.2
Consider the following situations:
Two nurses select the (same) wrong vial of
intravenous medication from the dispensing system.
One nurse administers the drug, causing
cardiac arrest. The other nurse realizes the switch
when drawing the solution from the vial into the
syringe at the bedside. How do we approach the
nurses and investigate the situation?
The attending physician tells a resident physician to
obtain a specific blood test. The resident forgets.
Fearing the wrath of the supervising physician, the
resident reports that the result is normal. How do we
deal with this breach?
A surgical team does not perform a surgical time
out on the grounds that no adverse events have
occurred in the past. How do we handle this
violation?
The night nurse supervisor reports to a medical
director that the lead respiratory therapist was in the
hospital at 4:00 am with alcohol on his breath. At a
Address correspondence to
Philip G. Boysen II, MD, MBA, FACP, FCCP, FCCM
Department of Anesthesiology
Ochsner Clinic Foundation
1514 Jefferson Hwy.
New Orleans, LA 70121
Tel: (504) 842-0796
Fax: (504) 842-2036
Email: pboysen@ochsner.org
Keywords: Behavior, medical errors, patient safety
The author has no financial or proprietary interest in the subject
matter of this article.
400 The Ochsner Journal
The Ochsner Journal 13:400–406, 2013
Academic Division of Ochsner Clinic Foundation
later date, the physician confronts the employee
who vehemently denies alcohol abuse. Should the
matter be dropped?
In only one of these scenarios does an adverse
event occur, yet a just culture, with its insistence on a
value-based culture and shared accountability, demands
that all of these situations be addressed.
However, individual practitioners should not be held
accountable for mistakes made in a system they
cannot control.3
In the first example, further investigation showed
that the 2 vials of entirely different medications looked
alike in shape, size, color, and print. This accident
waiting to happen did happen to the first nurse and
her patient. Human error was involved, but this nurse
should be consoled and supported rather than
punished.
The resident physician falsified patient data, which
cannot be condoned and must be addressed. Honest
disclosure without fear of retribution is an important
characteristic of a just culture.
The surgical team cannot function outside of the
value-based principles designed by the organization.
Although this surgical team has never been involved
in an adverse event, one may occur in the future.
As for the respiratory therapist, in a just culture we
are concerned for the safety of our patients and we
are concerned for and care about each other. Further
nonpunitive investigation is necessary.
These examples address an aspect of just culture
that goes beyond ensuring that employees feel free to
report errors. Highly reliable organizations and industries
foster mindfulness in their workers. Weick and
Sutcliffe4 describe mindfulness in terms of 5 components:
1. A constant concern about the possibility of failure
2. Deference to expertise regardless of rank or status
3. Ability to adapt when the unexpected occurs
4. Ability to concentrate on a task while having a
sense of the big picture
5. Ability to alter and flatten the hierarchy to fit a
specific situation
Mindfulness throughout an organization considers,
but moves beyond, events and occurrences.
Everyone in the organization is continually learning,
adjusting, and redesigning systems for safety and
managing behavioral choices.
INDUSTRIES OUTSIDE OF HEALTHCARE
While the concepts of developing a just culture
and supporting team function may be new to healthcare—
spurred by publication of Errors in Medicine in
2000—the just culture environment has been imbedded
in other industries for many years.5 The industries
of aviation, train transportation, and nuclear power
have been accepted as highly reliable and safe.6 For
aviation, frequently compared to healthcare, these
principles and their foundation span 45 years.7
Nonetheless, within these just culture industries are
examples of errors, failures, and accidents that are
insightful and address human behavior in complex
systems.8
Chatsworth Train Collision, 2008
The Chatsworth train collision occurred on the
afternoon of Friday, September 12, 2008 at the
beginning of the evening commute in a high-density
travel corridor.9 This mass casualty accident brought
a massive emergency response by the city and
county of Los Angeles, taxing resources to the
breaking point. Twenty-five people died, and many
survivors were hospitalized for an extended period.
The Metrolink train company was exposed to more
than $200 million in liability judgments.
Investigations revealed that the train engineer did
not obey a signal to not enter a single-track segment
(designated as such because of oncoming train
traffic). The Metrolink passenger train and a freight
train were headed toward one other, both moving at a
speed of 40 miles per hour. The engineer of the
freight train engaged his air brake 2 seconds before
impact, while the engineer of the passenger train did
not engage his brake. Further investigation revealed
that the engineer in the commuter train had a habit of
text messaging while operating the train and had
been warned about this policy violation. Nevertheless,
his cell phone history (delivered under subpoena)
showed 2 text messages sent shortly before impact. A
spokeswoman for the train company admitted the
strong likelihood of operator error and was chastised
by the firm as a result. She resigned.
U.S. Airways Flight 1549, 2009
Flight 1549, an Airbus A-320, departed LaGuardia
Airport in New York City bound for Seattle-Tacoma
International Airport with a stopover at the Charlotte-
Douglas International Airport. The aircraft carried 150
passengers and a flight crew of 5. Three minutes into
the flight, while still on the initial climb out of New
York, the airplane encountered a flock of Canadian
geese. A multiple bird strike with a total loss of power
in both engines is a highly improbable occurrence,
but this event is exactly what occurred.10 Within
seconds, the crew determined that the plane would
be unable to reach an airfield; the captain turned
south along the Hudson River in a glide mode and
ditched the aircraft in the river near the U.S.S. Intrepid
Museum within 3 minutes of losing power. All 155
persons aboard the aircraft were rescued while the
Volume 13, Number 3, Fall 2013 401
Boysen, PG
aircraft was still sinking, and only minor injuries
resulted. The accident investigation revealed crew
management at its finest, with the pilot communicating
and the copilot audibly reading aloud procedures
to ditch the aircraft. Captain Sullenberger and his
crew were widely acclaimed for their performance
under pressure. A former Air Force pilot with a
graduate degree from Purdue University in human
factors, the captain asserted that his highest duty and
obligation have been to safety. A pilot colleague
commented ‘‘If an unlikely tragedy like this had to
occur, I can think of no other pilot I would pick to
handle it other than Sully!’’
The Chernobyl Accident, 1986
The Chernobyl accident in the Ukraine is the only
accident in the history of nuclear power that resulted
in fatalities from radiation.11 An explosion and fires
released the contents of the reactor core into the
atmosphere, and radioactive material moved downwind.
The 2 plant operators died immediately; another
28 people died of acute radiation poisoning. The
disaster provides insight into the serious consequences
of ignoring safety issues. Investigation after the
event revealed a flawed reactor design compounded
by inadequately trained personnel operating the
facility. Twenty years later, the only resulting public
health issue is an increased incidence of thyroid
cancer.
Applications in Healthcare
These anecdotes and exhaustive investigational
material from other industries indicate several points
that apply to the healthcare environment.
1. As in aviation, aspects of medical care (anesthesiology,
surgery, emergency medicine, intensive
care medicine) are event driven and dynamic,
complex and tightly coupled, and uncertain and
risky.8
2. Written checklists help prevent crises.
3. Established written procedures are vital in crises.
4. Training in decisionmaking and crew resource
management are valuable.
5. Systematic drills and practice using simulation
technology address the ability to handle crisis
situations.
ANALYSIS OF ERROR
In a landmark publication, Reason presented a
detailed analysis of human error.12 Reason introduced
his text by referring to the 1928 studies of
Spearman but asserted that the decade prior to the
publication of his book was characterized by public
concern about the terrible cost of human error. He
lists the Tenerife runway collision in 1977, the Three
Mile Island crisis in 1979, the Bhopal methyl
isocyanate disaster in 1984, the Challenger and
Chernobyl explosions of 1986, the capsize of the
Herald of Free Enterprise, the King’s Cross tube
station fire in 1987, and the Piper Alpha oil platform
explosion in 1988 as causes for a collective impetus
to address error. Furthermore, this decade made
clear that the nature and scale of such tragedies
impacted wide geographic areas and generations of
humans.
Perhaps the most significant contribution of
Reason’s work was his development of a model for
the dynamics of accident causation, sometimes
referred to as the Swiss cheese model (Figure 1).
The author identified what he describes as latent
failures at the managerial level before the possibility
for human error is even involved. As described by
Reason, latent errors are those
. . . whose adverse consequences may lie dormant
within the system for a long time, only becoming
evident when they combine with other factors to breach
the system’s defences . . . Latent errors . . . are most
likely to be spawned by those whose activities are
removed in both time and space from the direct control
interface: designers, high-level decision makers, construction
workers, managers and maintenance personnel.
Latent errors exist in complex systems. Reason
uses a medical metaphor, describing them as
Figure 1. Reason’s model of accident causation. Accident
opportunity and possible adverse outcomes stem from a
combination of latent failures, psychological precursors, event
triggers, and failure of the system’s defenses. (From Reason12
with permission.)
402 The Ochsner Journal
Just Culture
resident pathogens, much like microorganisms, that
can exist in an organism only to emerge and
proliferate when defenses are inadequate.
Reason’s model of accident causation begins with
latent failures, and the Swiss cheese plates represent
psychological precursors and unsafe acts, local
triggers, and failures of other defenses. The trajectory
of error opportunity results from the alignment of the
holes in the slices of Swiss cheese.
Gaba and colleagues13 adapted this model to the
practice of anesthesiology. Some of the latent failures
in this specialty include machine and process design
flaws, manufacturing defects, maintenance failure,
underlying disease, production pressure, fatigue,
and environmental factors. With a triggering event
and the failure of preventive measures (preoperative
evaluation, checklists, etc), an event occurs. The
clinician must respond with dynamic decisionmaking
to detect and correct the critical incident before it
results in an adverse outcome.
THE MILITARY AND THE AGENCY FOR
HEALTHCARE RESEARCH AND QUALITY
Safety—fostered by teamwork, leadership, and
communication—has been a major focus of military
efforts. Historical events illustrate this focus.
Lord Nelson
Admiral Lord Nelson was renowned as a leader,
military strategist, and communicator. His communication
skills extended beyond interpersonal relationships.
Communicating from his command ship
through a flag system, he was able to instruct his
entire fleet to come about as one to achieve
unorthodox strategies. With fewer and smaller ships,
but through precision ship positioning and gunnery
training, he defeated the Spanish Armada (once
thought invincible) and the allied French navy.14 Lord
Nelson understood leadership and communication in
a way that applies to medicine. His communication to
his sailors was safe, timely, effective, and always
oriented to the task at hand.
World War II
Officers on U.S. Navy warships during World War
II had an established means of verbal communication
during maneuvers:
CAPTAIN: Come right to 190, all ahead one-third.
BOSUN: Aye sir, right to 190, all ahead one-third.
The call out, check back, and other scripting
techniques ensured that orders were received, confirmed,
understood, and executed.
Military Aviation
Military aviation develops effective team leaders
on the ground, at sea, and in the air. Whether on land
or at sea, pilots assemble in a ready room to review
the mission, understand objectives, and unify the
team. Events are described, recorded, visually confirmed,
and processed. After flying the mission, a
second assembly of the pilots focuses on a thorough
debriefing. What went well? What went wrong? Were
objectives accomplished? What areas can be improved?
What is the next step?
Coast Guard
The U.S. Coast Guard Academy has a unique
method of emphasizing and developing teamwork
and team leaders. All cadets serve aboard the
Eagle,15 a square-rigger sailing ship with an intricate
system of masts, stays, halyards, and sheets.
Effective and coordinated teamwork is essential when
underway, and the cadets learn not only seamanship
but ‘‘team-man ship’’ on a 30-60 day cruise. The
training emphasizes safety, as expressed in the
published command philosophy of a recent captain
of the Eagle15:
Safety. Above all, Safety. We learn safe practices and
procedures. We follow them on board and ashore. We
watch our shipmates to ensure they do too. We
immediately speak up when we think we see an unsafe
practice developing. We listen. We care about the
safety of our shipmates and ourselves. If any situation
tests our commitment to safety, safety comes first.
Strategies and Tools to Enhance Performance
and Patient Safety
These same leadership and communication skills
can be successfully applied to healthcare. The U.S.
Congress commissioned the Department of Defense
and the Agency for Healthcare Research and Quality
(AHRQ) to translate the principles of a just culture into
a format applicable to the delivery of healthcare.16
The result of this collaboration was the TeamSTEPPS
(Strategies and Tools to Enhance Performance and
Patient Safety) approach to patient safety. Consistent
with the principles demonstrated in the above military
examples, TeamSTEPPS focuses on leadership and
communication skills (with scripting), mutual support
of team members, and situation monitoring. It
identifies barriers, suggests observation tools, and
focuses on outcomes. TeamSTEPPS also helps
participants assess whether the safety culture is
being sustained.
The goal of TeamSTEPPS is the establishment,
nurturing, and preservation of a just culture in which
‘‘we immediately speak up when we think we see an
unsafe practice developing.’’17
Volume 13, Number 3, Fall 2013 403
Boysen, PG
CREATING A JUST CULTURE
Functional issues must be addressed in a just
culture.18,19 While encouraging personnel to report
mistakes, identify the potential for error, and even
stop work in acute situations, a just culture cannot be
a blame-free enterprise. Competency is one issue, but
even competent professionals make mistakes. In
complex, dynamic, and inherently risky environments,
society has an expectation for human performance.
After identifying an adverse event or near miss, the
investigation procedure technique becomes paramount
(Figure 2). Two approaches have been
successfully implemented in hospitals.
Outcome Engineering Algorithm
Marx2 coined the term outcome engineering that
is applicable to healthcare and other industries. His
algorithm lists 3 basic duties:
1. Duty to produce an outcome
2. Duty to follow a procedural role
3. Duty to avoid unjustifiable risk
Consequently, with breach of duty, the mechanism
of the breach is categorized into one of the
following:
1. Human error
2. At-risk behavior (a conscious drift from safe
behavior)
3. Reckless behavior (conscious of conduct and risk)
Reason12 highlights the notion of intent when
considering the nature of error. Slips (eg, Freudian
slips) lack intention; that is, the actions are not carried
out as intended or planned. Lapses are missed
actions or omissions, with the perpetrator often
conscious of the action and believing that it will not
lead to harm.
Mistakes involve error, ie, faulty planning or
intention; the individual involved believes the action
to be correct. Corrective action and coaching, not
punishment, are indicated for improving the system.
At-risk behavior includes both intention and the
violation of rules, policies, and procedures and makes
a system vulnerable, increasing risk. The individual
Figure 2. Caregivers’ actions and recommended responses for analyzing risks constructed from outcome engineering principles
and analysis of human factors. (From Leonard and Frankel19 with permission.)
404 The Ochsner Journal
Just Culture
should be coached to understand the risks resulting
from his or her action.
Reckless behavior may be grounds for disciplinary
action, and civil or criminal charges may be filed
against the individual. Punishment, including termination,
may be the appropriate consequence.
Repetitive patient safety problems must be addressed,
whether caused by individual error or
system weakness.20
United Kingdom National Health Service Algorithm
The National Health Service in the United Kingdom
and the National Patient Safety Agency published
an incident decision tree and a guide for its
use.21 The algorithm on which the decision tree is
based identifies the role of an individual and the given
specific outcome. The decision tree has 4 main
elements:
The deliberate harm test: a conscious and deliberate
breach of duty resulting in patient harm. The
goal of the institution or system is to establish or
refute this violation immediately as a first step.
The physical/mental health test: a provider is
impaired for any reason, including substance
abuse. The impact of impairment or the patient
outcome must be established.
The foresight test: once the deliberate intent to
harm and physical/mental health tests have been
discounted, this analysis establishes whether protocols,
policies, and procedures have been followed.
The substitution test: this test asks the question,
‘‘Would another provider put in the same circumstances
in the same systems environment make the
same error?’’
Combination of Models
Because both algorithms have merits, Leonard
and Frankel19 schematically integrated them into a
single format that involves a 3-step process. The first
step analyzes the individual caregiver’s actions via 5
measures: impaired judgment, malicious action,
reckless action, risky action, and unintentional error.
The second step determines if other caregivers with
similar skills and knowledge would react the same
way in similar circumstances. The final step is the
important determination of whether the present
system supports reckless or risky behavior and thus
requires redesign.
CONCLUSION
A fair and just culture improves patient safety by
empowering employees to proactively monitor the
workplace and participate in safety efforts in the work
environment. Improving patient safety reduces risk by
its focus on managing human behavior (or helping
others to manage their own behavior) and redesigning
systems. In a just culture, employees are not only
accountable for their actions and choices, but they
are also accountable to each other, which may help
some overcome the inherent resistance to dealing
with impaired or incompetent colleagues.22
Secondary benefits of a just culture include the
ability to develop a positive patient safety profile to
respond to outside auditors such as The Joint
Commission.23 When implemented, a just culture
fosters innovation and cross-departmental communication.
An example is the opportunity to revitalize the
morbidity and mortality conference to cross specialty
lines and develop a patient-centered focus.24
In a just culture, both the organization and its
people are held accountable while focusing on risk,
systems design, human behavior, and patient safety.
Safety. Above all, Safety.
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This article meets the Accreditation Council for Graduate Medical Education and the American Board of
Medical Specialties Maintenance of Certification competencies for Patient Care and Professionalism.
406 The Ochsner Journal