Instituting a just culture

In many situations, the correct action promoting a just culture is not intuitive. It is human nature to become upset and seek “justice” when a patient is severely injured, yet our response to events and near misses should not be based upon actual outcomes, rather upon the potential for patient harm.

Individual responsibility for the problem needs to be decoupled from injury severity. Sometimes an event without any harm should lead to significant employee discipline. Other times an employee may severely injure a patient, yet an analysis of the situation shows that it was the organization’s equipment, processes, systems, or work environment, not the employee, that was at the root of the problem.

To assist in changing event investigation techniques, several algorithms have been developed. On this page we describe two: one by David Marx that is in use in many California hospitals, and the UK National Health Service algorithm used throughout the United Kingdom. These algorithms function differently. To avoid confusion, organizations should not simultaneously use both.