Wednesday, December 11, 2013

A Just Culture Fosters a Safer Culture

When I was a medical student I had the opportunity to scrub on a bowel resection surgery for a patient with colon cancer along with a second year resident and the attending surgeon. I was holding a retractor and watching the case up close, watching as the surgeon sewed one end of the anastomosis (reconnection of the two pieces of bowel) to the other. But then, I watched as he started cutting right through the bowel he had just meticulously stitched. I knew this was wrong and I was scared. Could it be that this surgeon was actually cutting through the bowel section he had just stitched or was I not seeing this correctly?  I thought, ‘I’m just the med student,’ and I stayed quiet. As he was almost finished with the procedure, he stopped and looked at me and the resident and said, “Why didn't you say anything?” He realized that he was cutting through the anastomosis he just stitched. Not speaking up because of the hierarchy and the fear of retribution is very dangerous in any high risk industry, and especially in healthcare.

One of the problems in healthcare is that our field is very paternalistic and hierarchical. We must make it safe for people to speak up in order to make the care safer.

No one questions that the doctor is the captain of the team by training and by law, but to get it right it takes the whole team. For the team members to perform at maximum capacity there has to be a culture of respect and openness to full participation by all.

The Just Culture is a concept where individuals are consoled if they make a human error. They’re coached if they are drifting into at-risk or risky behaviors and they are only punished if they are involved in reckless behavior or knowingly put someone in harm’s way by violating the established rules.

Let me give you some examples of this:

A busy hospitalist physician inadvertently clicks on the wrong patient in the order entry system and orders insulin on the wrong patient. The pharmacist, not seeing the diagnosis of diabetes in the patient’s record, calls the physician who realizes her error and apologizes, feeling terrible for her mistake. The pharmacist consoles her.

A nurse later draws up the insulin but gets distracted by her phone ringing and draws up the wrong dose. Because insulin is a high-risk medication and patients can be harmed by receiving too much or too little insulin, we have a double check on insulin delivery – one nurse draws up the insulin, checks it against the physician order and then hands the syringe to a second nurse who must double check the dose against the written order to make certain it is the correct amount. In this case, the second nurse, also feeling pressed for time to give care to his patients looks at the syringe but does not check it against the actual order. The first nurse then gives the incorrect dose to the patient.

These two nurses are drifting from the design for safety – they did the second check but did not do it the designed way. In this case, their behavior is risky and they need to be coached on why the second check is done and why it is critical to do it correctly.

Reckless behaviors, on the other hand, need to be punished. Take, for example, the medical technician who was sentenced to 39 years in prison for infecting more than 45 patients with Hepatitis C after he stole syringes filled with narcotics intended for the patients, injected himself with the drug, refilled the syringes with saline and then used the syringes on patients knowing he had hepatitis C. This is reckless and dangerous behavior and in a just culture, should be, and is, punishable by law.

To err is human

Commercial aviation had to make dramatic changes to its culture because of the worst airline disaster in history - the Tenerife crash of 1977 where two 747s crashed into each other.  The co-pilot of the one plane on the runway was aware that they hadn't been cleared for take-off but feared speaking up to the pilot who was the most distinguished captain in the KLM fleet at that time. The co-pilot failed to speak up to this pilot and they died, along with 500+ other people. After this disaster, commercial aviation began to work on removing the barriers to open communication in the cockpit and everyone who travels on planes benefits from this today. Building a just culture is a step towards making our care safer.
Humans make mistakes; this is a simple fact. But without a just culture, people who make human errors may be punished, thereby decreasing the likelihood that they will report errors that lead to harm. When errors and near misses are not reported, we miss the opportunity to learn from these events and design systems to catch the errors.

Last week, our physicians of Greater Baltimore Medical Associates spent some time learning about the Just Culture and studying examples of its application. I am very grateful for their engagement in making our care even safer than it already is.


  1. Promoting q just culture is the responsibility of every person in the GBMC system. Asking people to speak up is a very important part of growing this culture; always having a just response from the system is equally important. Its a journey and we all need to be on it together to make it work.


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