A 'Just Culture' Is The Right Culture For Improving Patient Safety

Main Category: Litigation / Medical Malpractice
Article Date: 07 Jan 2009 - 3:00 PDT

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Human error occurs in the health care environment and sometimes those errors harm patients. In the December 2008 issue of Urologic Nursing, Celeste M. Mayer and Dale Cronin say that to improve patient safety, the health care industry must find ways to detect and learn from mistakes, holding the system accountable for errors, instead of focusing on the individual(s) responsible.

Often, systems factors in health care, including interdependent work variables involving humans, equipment, information technology, activity monitoring and social relationships, contribute to patient harm as much as individual mistakes. The authors say why an event occurred is much more important than the human error.

Organizations should aim for a culture of safety, one in which organizational leaders value learning, reporting and fairness. In this "just culture," say the authors, "human error is recognized as unintentional and does not lead to disciplinary action." Error, blame and discipline are balanced. Organizational leaders are responsible for maintaining this balance and making systems improvements.

According to Mayer and Cronin, a just culture can only exist if leaders understand the value of such a culture. In a just culture, staff is not afraid to report events, information gained from reports is used to make performance improvements, and leadership seeks new ways to protect patients from harm.

(Organizational Accountability In a Just Culture; Celeste M. Mayer, PhD, BSN; Dale Cronin, BSN, RN; Urologic Nursing; December 2008; http://www.suna.org)

About SUNA

The Society of Urologic Nurses and Associates is a national, non-profit professional membership association with over 3,000 members and annual revenues of $1.5 million. SUNA derives its income from membership dues (only $60), conference registration fees, exhibits, advertising, grants, and the sale of educational products.

SUNA publishes a professional, peer-reviewed bi-monthly journal (Urologic Nursing Journal) and a bi-monthly newsletter (Uro-Gram). SUNA establishes the scope and standards of urologic nursing practice and the scope and standards of advanced urologic nursing practice. SUNA provides scholarships, grants and awards to deserving nurses and other health care professionals.

SUNA supports and promotes the certification of urologic nurses and associates by providing educational preparation for the examinations offered which lead to certification in three areas.

SUNA provides a variety of opportunities for participation including local chapters, task forces and Special Interest Groups (SIGS) in five major subspecialty areas.

Society of Urologic Nurses and Associates