Posted by: ayrshirehealth | September 7, 2012

Just culture by @di962

Human Factors

Healthcare organisations must recognise that skilled humans will make mistakes, and that the complexity of such organisations often predisposes this.

When this is recognised by Organisations and the focus is shifted to systems failures and takes account of human factors it makes it easier for clinicians to become part of the solution and disseminate the learning.

In 1997 James Reason [1]eminent Professor of Psychology, described just culture as “an atmosphere of trust in which people are encouraged for providing essential safety related information, but in which they are also clear about where the line must be drawn between acceptable and unacceptable behaviours”.


The implementation of a just culture approach supports and encourages learning when things go wrong but also identifies where accountability lies. Much has been researched and written about in this area, but one thing authors such as Dekker[2], Marx[3], Leape[4], Leonard and Frankel[5] have concluded is; when things go wrong it is only in the minority of cases have they identified wilful or malevolent behaviour.

Dekker advises that for people to speak up about incidents and participate in their review leaders must describe and define how incidents will be reviewed and identify where the line of accountability will be drawn.

He also advises that it is critical to identify who has the legitimacy in the organisation to draw the line.

These esteemed authors offer useful guides to aid decision making to discriminate between wilful and malevolent behaviour and the behaviours usually seen when things go wrong, such as omissions, slips and lapses, mistakes and rule violations of policies and procedures. The authors all agree that skilled humans will make mistakes and that errors and mistakes are often caused by poor systems and processes.

Beside the patient and family the frontline staff often have the most to lose when things go wrong and may become the “second victim” a term coined by Albert Wu in 2000[6]

Scott, 2011[7], suggests that when things go wrong some clinicians may experience an intense period of personal and professional anguish and with no one to turn to and they can find themselves suffering in silence, feeling responsible and second guessing their clinical skills and knowledge.

Supportive organisations

To support patients, families and clinicians organisations should ensure the following;

1. Clear and unequivocal leadership that promotes a culture of candour

2. Respectful disclosure of significant adverse events to patients and families

3. Timeous review of what went wrong to identify; root causes and learning and improvement

4. Clear commitments to patients and families of what they can expect following a significant adverse event

5. Clear commitments to staff, of what they can expect when things go wrong, including support that they may access and where lines of accountability will be drawn.

6. Closing the loop through the effective delivery of learning and improvement.


To adopt a culture that is “just” leaders must continually reinforce transparency to encourage willingness to discuss incidents, accidents and near misses.

An organisation where there is clarity of accountability will be fair and just with every employee group working to the same standards and rules.

Changing the culture to ensure that every employee believes that this will be the case is a journey that will take time and considerable effort.


Next week features experienced journalist and health communications specialist Pennie Taylor (@ptupdate) who writes about social media and NHS Scotland. Pennie is a renowned champion of public and staff involvement in Scotland’s health and care services, former Health Correspondent for BBC Scotland and was the founding Health Editor of the Sunday Herald newspaper.


References used in this blog

[1] Reason J (1997) Managing the risks of Organisational Accidents. Hants, England, Ashgate Publishing Ltd

[2] Dekker.S. (2007) Just Culture: Balancing Safety and Accountability. Surrey, England, Ashgate Publishing Ltd

[3] Marx D. Patient Safety and The “Just Culture”: A Primer for Healthcare Executives 2001. (accessed 6 September 2007)

[4] Leape. L. (1994) Error in medicine. JAMA, 272(23), 1851-1857.

[5] Leonard .M. Frankel .A. The Path to Safe and Reliable Healthcare Vol 80, Issue 3, pages 288-292.

[6] Wu. A. Medical Error: The second Victim. The Dr who makes mistakes needs help too.BMJ 2000; 320:726-727.

[7] Scott. S. The second Victim Phenomenon: A harsh reality of healthcare professions 2011 6 September 2012.



  1. Good to surface and discuss. Clinicians are human with human emotions and make mistakes. We need to recognise learn and support rather than blame

  2. Really enjoyed reading this….. in my experience, where the culture is right within clinical teams, the improvement effort involves everyone in a safe learning journey where team effort and full engagement flourishes. With a focus on improving processes, so much can be achieved to support individuals and teams to realise their full clinical and professional potential.

  3. […] One of the Ayrshire Health bloggers Diane Murray looks at the fascinating concept of “Just culture” and how it can ultimately lead to better […]

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