Improve the quality and safety of patient care in your facility by creating a just culture. A just culture not only promotes professional accountability and reporting of medical errors or near misses, but also fosters a professional interdisciplinary environment where actions are analyzed and actual or potential errors are evaluated in an open and fair milieu. In addition to the existing position statement "Creating a Practice Environment of Safety", these resources provide periOperative professionals with pertinent articles, videos and other resources to assist in exploring and developing a just culture.
Components - Members Only
You need the appropriate tools to implement a just culture at your facility. Implement a just culture by including the following tools:
- Just Culture Reason Algorithm (PDF) provides a six step decision tree that will help you determine accountability when an error, near miss or unsafe act occurs.
- The Just Culture Scenarios (PDF) were created to assist in understanding the concepts of a just culture and the behavioral concepts of human error, negligence, intentional rule violations and reckless conduct.
- The Just Culture Bibliography (PDF) contains numerous articles to expand your understanding of the just culture concept.
AORN Position Statements
Related External Links
Educate your institution and team. Have managers and all staff that are important to implementing a just culture at your institution review the following:
- Fair and Just Culture, Team Behavior and Leadership Engagement: The Tools to Achieve High Reliability – Allan S. Frankel, Michael W. Leonard, Charles R. Denham (doi: 10.1111/j.1475-6773.2006.00572.x) This article explores three facility initiatives that have promise in shaping operational change: The implementation of fair and just culture principles, teamwork training and communication, and tools that promote the cyclical flow of information.
- From a blame culture to a just culture in health care – Khatri N, Brown GD, Hicks LL. (Health Care Manage Rev. 2009;34(4):312-322. doi: 10.1097/HMR.0b013e3181a3b709.) The authors of this article maintain that moving from a blame culture to a just culture requires an understanding of your organization’s attributes and historical evolution that have shaped the current culture and that building a just culture will require a human capital investment. This article is listed in the bibliography.
- ANA Position Statement on Just Culture Concept
- National Quality Measures Clearinghouse
- CAHP® Surveys and Tools to Advance Patient-Centered Care
- ISMP: Just Culture and Its Critical Link to Patient Safety (Part I) – May 17, 2012
- ISMP: Just Culture and Its Critical Link to Patient Safety (Part II) – July 12, 2012
- Pennsylvania Patient Safety Advisory - Gap Assessment of Hospitals' Adoption of the Just Culture Principles – December 2011
- Culture of Safety - ECRI Institute (PDF) – January 2009
- Promoting a Culture of Safety: Use of the Hospital Survey on Patient Safety Culture in Critical Access Hospitals (PDF) – April 2012
- ISMP: Dr. Leape and colleagues present a compelling call to action to establish a culture of respect – June 14, 2012
Why do errors happen? How can we prevent them?
David Marx introduces the Just Culture Toolkit
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