ACR Bulletin

Covering topics relevant to the practice of radiology

To Err Is Human

Just culture is the most important concept in healthcare safety.
Jump to Article

Instead of placing the blame on the healthcare provider, a just culture places the blame on the system.

December 01, 2019

Despite our best efforts, things in healthcare do not always go as planned. Mistakes happen. Patients get injured. In fact, mistakes will continue to happen in healthcare as long as we remain human. Human error is by far the most common behavior resulting in healthcare mistakes, accounting for approximately 85% of errors. Recognizing this, our goal as committed healthcare professionals should be to drive down the number of mistakes to the lowest achievable level.1

A basic tenet of a just culture is that errors due to system failings should not be accountable to the individual practitioners who fall prey to them.5 A just culture is an environment in which errors and near-miss events are evaluated in a deliberately non-punitive framework — avoiding a culture of blame and focusing instead on error prevention and fostering a culture of safety and quality improvement.2 Fundamental to just culture is the recognition that errors inevitably occur, even by the most qualified healthcare practitioners.4 The adoption of a just culture requires careful attention to detail and relies on continuous coaching of individuals and teams to ensure systems improvements.2 Regardless of the clinical impact of any singular event, the focus of the framework is on avoiding future error.4

In a just culture, healthcare providers are not punished for human error. Punishing healthcare providers for human error destroys their confidence, erodes their trust in the healthcare system, and ensures future mistakes will not be freely disclosed — lest additional punishment ensue. In doing so, punishment impairs the surveillance function of quality and safety and blinds us to our problems. Instead of placing the blame on the healthcare provider, a just culture places the blame on the system. Just culture asks how we can build a system that limits the number and effect of our human errors. As such, we look for areas of improvement and try to alter the system to prevent the mistake in the future — implementing checklists, safeguards, and automation where appropriate.1

Fundamental to just culture is the recognition that errors inevitably occur, even by the most qualified healthcare practitioners.

Despite our best efforts, things in healthcare do not always go as planned. Mistakes happen. Patients get injured. In fact, mistakes will continue to happen in healthcare as long as we remain human. Human error is by far the most common behavior resulting in healthcare mistakes, accounting for approximately 85% of errors. Recognizing this, our goal as committed healthcare professionals should be to drive down the number of mistakes to the lowest achievable level.1

A basic tenet of a just culture is that errors due to system failings should not be accountable to the individual practitioners who fall prey to them.5 A just culture is an environment in which errors and near-miss events are evaluated in a deliberately non-punitive framework — avoiding a culture of blame and focusing instead on error prevention and fostering a culture of safety and quality improvement.2 Fundamental to just culture is the recognition that errors inevitably occur, even by the most qualified healthcare practitioners.4 The adoption of a just culture requires careful attention to detail and relies on continuous coaching of individuals and teams to ensure systems improvements.2 Regardless of the clinical impact of any singular event, the focus of the framework is on avoiding future error.4

In a just culture, healthcare providers are not punished for human error. Punishing healthcare providers for human error destroys their confidence, erodes their trust in the healthcare system, and ensures future mistakes will not be freely disclosed — lest additional punishment ensue. In doing so, punishment impairs the surveillance function of quality and safety and blinds us to our problems. Instead of placing the blame on the healthcare provider, a just culture places the blame on the system. Just culture asks how we can build a system that limits the number and effect of our human errors. As such, we look for areas of improvement and try to alter the system to prevent the mistake in the future — implementing checklists, safeguards, and automation where appropriate.1

A just culture responds to at-risk behavior with education and training.1 Education might correct an inaccurate risk assessment or provide the rationale behind an unheeded policy. After an error like this, just culture also considers extending this education to other staff. After all, if one well-intentioned employee made the errant decision under those clinical circumstances, so might another.1

If just culture is to be used in radiology organizations, an honest, in-depth look needs to consider the leadership, the human factors, and the factors leading to poor performance. This process is not for the faint of heart or for those seeking quick improvements.3 It is a long-term commitment. However, as healthcare professionals, we have a duty to protect patients from avoidable harm when they are under our care.1

ENDNOTES

1. Harvey BH, Sotardi ST. The just culture framework. J Am Coll Radiol. 2017;14(9):1239-1241.
2. Boysen PG. Just Culture: A Foundation for Balanced Accountability and Patient Safety. Ochsner J. 2013;13(3):400–406.
3. Abujudeh HH. “Just culture”: is radiology ready? J Am Coll Radiol. 2015;12(1):4–5.
4. Burns J et al. Just culture: practical implementation for radiologist peer review. J Am Coll Radiol. 2019;16(3):384–388.
5. Brink JA. Is achieving “just culture” just culture, or something more? J Am Coll Radiol. 2017;(14):143–144.

Author Geraldine B. McGinty  MD, MBA, FACR, Chair