Just Culture – Making Mistakes In A Learning Culture

We all make mistakes. Human error is a part of life. In many everyday situations, each of us makes errors, and most of the time, these errors bear no significant consequences for our lives or the lives of others. You mistake your brown shoes for the black ones and end up looking mismatched for the rest of the day. Likely, you’ll recover from your inadvertent fashion faux pas. But if you’re a healthcare provider, and you mistake one medication for another, the consequences could be much more serious.

Historically, the healthcare field has been marked by a punitive mindset, such that all mistakes, even those that bore no ill consequences, were reprimanded. This punitive attitude, which initially developed from the desire of healthcare organization to safeguard themselves against all potential damages, eventually grew into an atmosphere that deterred even minor mistakes from being reported out of fear of punishment. This kind of atmosphere stifles constructive learning and tends to make providers feel unsupported by the healthcare systems in which then work.

Mistakes Can Grow Knowledge In Learning Culture

A healthcare learning culture is the opposite. A healthcare learning culture takes everyday occurrences, even mistakes, and uses them so that both organizations and providers can grow in knowledge, performance, and competence. A learning culture engenders a just culture, and a just culture fortifies a learning culture. Just culture seeks to create and reinforce a learning culture by providing a framework for managing mistakes and actions. Just culture acknowledges that all people, including system designers, make mistakes.

So, for the healthcare provider who mistook one medication for another, a just culture promotes an environment where the provider who made the error should not fear to come forward. A just culture investigates to see if the error was part of a system failure such that any provider in a similar situation would have made the same mistake.

A just culture, then, differentiates among unintentional human errors, system errors, mistakes made because of poor decision making, mistakes made because of disregard for procedures, and deliberate actions intended to be harmful. This differentiation helps determine the level of accountability and allows for a response on the part of the organization that is fitting and fair for the mistake maker.

Shift Focus to Management of Behavioral Choices

Just culture is founded in the belief that all stakeholders -from healthcare providers to business leaders- are responsible for the quality and safety of services. It demands that providers adhere thoughtfully and safely to clinical standards; furthermore, it expects that even minor errors are reported so that broader learning needs and system failures can be identified. In a just culture, errors become opportunities for the organization and all its providers, not just those who make mistakes, to learn and improve, which greatly reduces the chance that an error will be repeated.

Just culture shifts the focus of quality improvement from punishment and faultfinding to the management of behavioral choices in the context of the systems in which providers work. Medcor has found that embracing a learning culture and a just culture increases providers job satisfaction and adds significant value to our quality improvement processes. Just culture treats our advocates with fairness and respect and makes our leadership consider how we can improve our systems to promote the best outcomes for our employees, patients, and clients.

Author Dr. Sharon Moise, Chief Medical Officer, Medcor. Dr. Moise joined Medcor in 2015. Sharon is board-certified in emergency medicine and has extensive experience in occupational health, urgent care, clinical education, and clinical quality. Sharon provides broad clinical oversight for Medcor’s Worksite Clinics, Injury Triage Service, and supports all Medcor’s lines of business. In addition to involvement in many of Medcor’s projects and initiatives, Sharon is passionate about clinical quality and chairs Medcor’s Clinical Quality committee.