Step forward: Hospitals’ journey to ‘Just Culture’

Just Culture: All humans make mistakes; errors are opportunities; and safe systems support smart choices.

Anyone can make a mistake, but in industries such as aviation and health care, one small mistake can lead to dire consequences and loss of life. In the past, a person who made a mistake or reported an error was punished. That is now changing, thanks to the “Just Culture” concept being pioneered by David Marx.

“It’s like that whack-a-mole game—individuals are punished for errors,” said Marx, CEO of Outcome Engenuity, a company that teaches industries how to investigate events and produce better outcomes in a nonpunitive manner. “We need a better way to deal with human fallibility rather than whacking people into submission.”

Under the Just Culture concept, safety is promoted by facilitating open communication within an organization in addition to a system of accountability for safe behavioral choices among staff. Just Culture is about holding human beings accountable, but it is also about digging deeper and looking at the system to determine why a particular error occurred.

“The core message for pharmacists is that you are a fallible human being and you’re going to make mistakes—it’s inescapable,” Marx said in an interview with Pharmacy Today. “We can influence the system design to change the rate of errors, but perfection just isn’t in the cards.”

Culture shift

Marie Link, PharmD, System Medication Safety Officer for University Hospitals in Cleveland, evaluates medication use across all clinical disciplines to improve standardization, safety, and the quality of patient care. Just Culture plays an integral role in the success of these objectives.

“The Just Culture concepts have changed our environment. We have evolved to a mindset where the error is treated as a system error rather than an error caused by an individual,” Link explained. “Just Culture allows staff, from the bottom to the top, to communicate and discuss sensitive issues more freely; this is [critical] to improving patient care.”

Event reporting

Just Culture at University Hospitals health system was rolled out in 2009 to support efforts to improve transparency and increase medication event reporting by staff. “It is well established that voluntary reporting only captures the tip of the iceberg,” said Link. “How can an organization uncover and learn from the additional information that lies below the surface?”

If a pharmacist sees a particular error trend with a medication or identifies areas where patients could be at risk, “Just Culture promotes a positive environment to encourage the pharmacist to raise up their concern,” said Link.

With Just Culture, University Hospitals has seen an increase in the number of medication events reported and has enhanced their root cause analysis (RCA) process. “Part of the success of gathering information is in creating ways for all staff to be involved in improving patient care,” added Link.

Always communicate

When a medication error or safety event occurs, “it is important to discuss it ,” Link told Today. “An RCA is scheduled with a multidisciplinary group to walk through the event, determine how it happened, and identify the changes needed to prevent it from happening again.”

Pharmacists are key players in an RCA because “they understand potential for harm related to the use of medications and likelihood of potential errors,” said Link. “Pharmacists can provide valuable recommendations for resolution and prevention.”

Being human

“As humans, we are raised to understand that if you make a mistake, you are going to be punished, whether you meant to make the mistake or not,” said Natasha Nicol, PharmD, FASHP, Director of Medication Safety at Cardinal Health in Dublin, OH. “Just Culture goes against that and says no, we need to understand and know and accept and learn that human beings make mistakes. We need to plan for that in order to understand the causes behind the mistakes and build risk reduction strategies to stop errors from happening.”

Nicol studied under Marx, is a certified Just Culture trainer, and teaches hospitals across the nation how to implement and sustain Just Culture practices.

Behavioral choices

An important element of Just Culture in health care is to make sure that hospital staff has the safest possible systems, procedures, and policies in place. At the same time, health care personnel should understand that they need to make safe behavioral choices.

“This is where people drift. They say OK, I know I’m supposed to do it this way, but I do it a different way because it’s faster,” Nicol explained.

An organization needs to look at the entire system and determine if a policy or procedure makes sense. “They need to understand why people make the behavioral choices they do,” said Nicol.

For example, Nicol is working with a hospital system in Alabama to implement Just Culture and improve medication processes, from the time a physician thinks about writing an order until the medication is being monitored in the patient’s body. Nichol reviewed the hospital’s scanning rates for bedside bar coding. Although the hospital’s leadership thought nurses were doing a great job of scanning, “it turns out that the nurses hardly ever truly scanned the arm band on a patient,” she said. “We had to look deeper to understand the reasons behind this behavioral choice.”

It turns out that the nurses weren’t scanning the bar codes on the patients’ armbands because often the bar codes don’t work. Sometimes this is a result of a printer error or the band getting wet or torn.

“The nurses said, ‘I know I need to confirm and scan the bar codes, but the system doesn’t work for me,’” said Nicol. Once she identified the barriers to complying with the bar code scanning process, the hospital began working on fixing the underlying problems so the process will work for the nurses.

Changes that matter

Nicol believes that a Just Culture is necessary to effect positive change. “Without Just Culture, hospitals will not be able to make medication use safer, and without Just Culture, people don’t feel comfortable talking, explaining, and sharing ideas about errors,” she said. For pharmacists, the key is to “move toward more standardization of procedures to help reduce errors.”

Lessons in Just Culture

Get over the notion that you can be perfect every day. “Don’t fret about making a mistake. If you want to worry, worry about whether you are making the right choices when you step into the pharmacy,” said David Marx, the father of Just Culture and a founder of the Just Culture Community.

According to Marx, human fallibility can be organized into three categories:

  • Human error
  • At-risk behavior
  • Reckless behavior

These three types of fallibility are each managed in a specific way. Human error, such as a slip, lapse, or mistake, is often a product of an organization’s current system design and is managed by consoling the individual with support and compassion, followed by an evaluation of the system for possible improvements that can be made to the processes, procedures, training, or environment.

By far the most prevalent behavior of the three, at-risk behavior—where an individual believes the risk is insignificant or justified—is managed by coaching. Removing incentives for at-risk behavior, creating incentives for safer choices, and realigning the individual’s perception of the risks they are taking can improve the individual’s behavioral choices.

Reckless behavior involves an individual consciously disregarding a substantial and unjustifiable risk. Reckless behavior is rare and is effectively managed through disciplinary measures and punitive actions.

“Although a person may be sorry that a mistake occurred, we need to figure out why that mistake occurred,” said Marx. “We need to look at the error and [understand] that it is really an outcome. The outcome is a product of the system and the performance-shaping factors within that system.”

In the Just Culture model, error events are seen as opportunities to understand risk. Once understood, new processes and programs can be applied to minimize the risk of harm. For pharmacists, this means designing “good systems that help them make good choices during the day,” said Marx.

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