The Doctor’s Advocate | Second Quarter 2023
Perspectives from the CMO

Building a Culture of Safety in Healthcare, Part Four: Just Culture

David L. Feldman, MD, MBA, FACS, Chief Medical Officer, The Doctors Company and TDC Group; Senior Vice President, Healthcare Risk Advisors

Consider the following scenarios:

A biomedical equipment technician repairs an infusion pump. Hospital policy requires consulting an instruction book for each repair, but on this occasion, the technician relies on his memory. He omits a required check, and when the faulty pump delivers an overdose of heparin, a patient dies.

A nurse working in a physician’s office is asked to refill a prescription. She looks in the EHR for the correct medication and dose, but the system is down. She remembers the patient was on amlodipine 5 mg, so she orders it in the pharmacy system. The pharmacist notices the dosage error (the patient was taking 10 mg) and makes the correction, so the patient gets the correct dose.

How should the hospital and the practice respond to these errors?

Share Accountability to Support System Safety

A just culture forms the capstone of a healthcare organization’s safety culture. A just culture is balanced, neither blame-free nor punitive. It is created when safety leaders recognize “the tension between holding the system accountable and holding the individual accountable.”1 Safety leaders in a just culture respond fairly to the individuals involved in a single incident of patient harm, and they also recognize the ways in which healthcare systems influence individual actions.2

Further, savvy safety leaders know that a just culture improves error reporting, which over time improves patient safety and mitigates liability for medical professionals and institutions.3

Scale Incident Response

When errors occur, safety leaders within a just culture stratify their organizational responses by degree of culpability.4 For instance:

Human error: People make mistakes. In responding to those mistakes—or better yet, in anticipating and preventing them—an organization with a just culture recognizes various principles of culpability. These include: (1) Individuals have an obligation to attempt to avoid mistakes, and (2) individuals cannot be held accountable for the ways in which their work systems—especially aspects of those systems that they do not control—may, perhaps, promote mistakes.5 (This is why we have the discipline of human factors engineering.6) In cases of simple human error, often the just response from safety leaders is to console the person who committed the error, and commit to implementing lessons learned in the management of processes, procedures, training, design of physical work spaces, and/or environmental factors.7

At-risk behavior: Most humans, even humans who value safe practices, have a tendency to drift into at-risk behaviors. For instance, have you ever driven 9 mph over the speed limit?4 At-risk behavior occurs when someone commits an action they know isn’t quite on the mark, perhaps because they have become desensitized to a certain risk. In most cases of at-risk behavior, the just culture response would be to coach the individual back to full adherence to policies and procedures. Safety leaders can then make responsive system changes, such as removing incentives to drift away from policies and protocols, creating incentives for healthy behavior, and integrating daily practices to increase situational awareness.

Reckless behavior: Consider the person driving 40 mph over the speed limit on the freeway while swerving around other cars, all to meet friends at a bar. This is an example of truly reckless behavior that the person knows is wildly out of bounds. The just culture response to reckless behavior may be to deliver consequences for the behavior. Safety leaders can minimize the potential for a repeat through some combination of remedial action and disciplinary action.

Focus on Choices, Not Outcomes

Leaders in a just culture do not determine whether to coach or terminate an employee based upon outcomes or actual patient harm. After all, a lucky individual may commit an act of outrageous recklessness but still watch their patient walk away unharmed (this time), while a careful but unlucky person in a dysfunctional system might experience the opposite result. Therefore, a focus on the degree of risk in an individual’s choices, not on outcomes, yields a more just response now, along with system insights that may help mitigate risks that will arise later.7

Cultivate Just Culture for a Safer Culture

Healthcare systems that punish human error promote a culture of fear. In addition to being unpleasant, a culture of fear deters reporting, which increases future risks.8

On the other hand, a just culture in healthcare encourages the reporting not only of actual medical errors, but also of near misses, systems that promote alert fatigue, cumbersome medical record workflows that create temptations to take shortcuts or skip documentation, and other potentials for hazard.3 This reporting occurs in the spirit of Dr. James Reason’s human error theory, which knows that a safety culture is a learning culture. When I interviewed Elizabeth Duthie, RN, PhD, CPPS, Director of Patient Safety at Montefiore Medical Center, she put it simply: “We can’t fix what we can’t see.”7

In other words, just culture is the ultimate pragmatic approach: It strives for excellence, not perfection, because it presumes that human error is inevitable, and it makes error reduction and management the aim.

Respond to Risk

Let’s consider where we started, with the biomedical technician working from memory instead of the manual, and the nurse who entered the wrong medication dose. The technician’s patient died, while the nurse’s patient got the correct medication through the pharmacist’s intervention.

In these types of situations, safety leaders might consider the following approach: Instead of responding based on a tally of the outcomes (which depend, in part, on system factors and plain luck), base your response on an estimation of the risks presented by the behaviors. This approach can move an organization toward a more just culture and result in safer patient care and a more satisfying work environment for healthcare professionals.

To learn more about just culture, listen to my interview with Dr. Duthie through the Leading Voices in Healthcare podcast.


  1. In conversation with . . . David Marx, JD. Agency for Healthcare Research and Quality, PS Net, Perspectives on Safety. Published October 1, 2007.
  2. Feldman DL. Building a culture of safety in healthcare, part one: mutual respect. The Doctor’s Advocate. Published September 2022.
  3. Paradiso L, Sweeney N. Just culture: it's more than policy. Nursing Manage. 2019;50(6):38-45.
  4. Marx D. Reckless homicide at Vanderbilt? A just culture analysis. A Just Culture Company. Published 2019.
  5. Boysen PG. Just culture: a foundation for balanced accountability and patient safety. Ochsner J. 2013;13(3):400-406.
  6. Feldman DL. Building a culture of safety in healthcare, part three: human factors engineering. The Doctor’s Advocate. Published March 2023.
  7. Duthie E. Just culture enables a culture of safety. Leading Voices in Healthcare Posted 2022.
  8. Eng DM, Schweikart SJ. Why accountability sharing in health care organizational cultures means patients are probably safer. AMA J Ethics. 2020 Sep1;22(9)E779-783. doi:10.1001/amajethics.2020.779

The Doctor’s Advocate is published by The Doctors Company to advise and inform its members about loss prevention and insurance issues.

The guidelines suggested in this newsletter are not rules, do not constitute legal advice, and do not ensure a successful outcome. They attempt to define principles of practice for providing appropriate care. The principles are not inclusive of all proper methods of care nor exclusive of other methods reasonably directed at obtaining the same results.

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