Mistakes are a fact of life. As the Institute of Medicine said in 1999, "To err is human." What matters is how we respond to mistakes, which involves putting systems in place to stop errors before they happen and supporting clinicians who make mistakes.
Not long ago, the catch phrase was "no blame" culture, where people talked about non-punitive responses to patient safety incidents. But simply saying "no blame" doesn't take the complexities of medical errors into account. Removing personal accountability from individuals isn't the answer, but neither is a rush to judgment and punishment that we know still occurs too often.
A balanced response that emphasizes individual and organizational accountability is Just Culture, a concept originating in aviation and crew resource management and lately honed by engineer David Marx. The Just Culture process involves purposeful responses to situations that investigate exactly what went wrong and why so as to understand everything, without falling prey to kneejerk emotional reactions that attribute blame.
One organization that has been working on establishing a Just Culture for the last few years is Lutheran Medical Center in Brooklyn. Rosanne Raso, RN, senior vice president, nursing services, says the most important concept of a Just Culture is to remove the emotional response that occurs whenever there is a medical error or a near miss.
"The old way of doing things was to have a kneejerk reaction and punish people and that doesn't fix anything," says Raso. "You have to investigate and look into why things happened. You can't make any decision or judgment about what happened until you really dig into the whys. You don't know how to fix it until you know what went wrong."
Just Culture emphasizes learning from every event and promoting a culture of shared accountability throughout the entire organization.