Today I received an email from the Medication Safety Officer's list service from a team at Cleveland Clinic Abu Dhabi containing a link to a
video on Just Culture. It is well done, and I recommend it you your viewing. It doesn't take long.
The video focuses on that portion of Just Culture that deals non-punitively with error and focuses, instead on the system issues that may have created an environment in which errors are more likely to occur.
As I viewed this video, I found myself thinking of recent conversations I have had with colleagues in which the notion of Just Culture was considered synonymous with never being punitive. While there is no doubt that many errors have significant components of system failure, it must be remembered that a Just culture actually recognizes that there are both system components and
human behavioral components to error, and among those components are 'at risk' and 'reckless' behaviors that require some action to be taken with the human who committed an error. Indeed, part of implementing a Just Culture must include developing organizational consensus around what constitutes at risk behavior, and reckless behavior. The big difference between a 'non-punitive' culture and a 'just' culture is the inclusion of recognition of behaviors that are risky, or downright reckless,
and systematically and appropriately addressing those behaviors when they are encountered, up to and including termination.So, as you think about building a just culture in your organization, how would you define 'at risk' or 'reckless' behavior? I would be interested to hear from you what you think those definitions entail (examples would be really great) and how you would deal with them if you encountered them?
Dennis A. Tribble, Pharm.D, FASHP
Ormond Beach, FL
DATdoc@aol.com
The contents of this post represent my own opinions, and not necessarily those of my employer or of ASHP