• It is refer to a safety-supportive system of shared
accountability where health care organizations are
accountable for the systems they have designed and for
responding to the behaviors of their staffs in fair and just
• Why did these accidents happen?
• What can we do to prevent them from
• How do we judge the
How would your organization deal with ?
1- Wrong prescription from a doctor.
2- Ignoring the patient ring bell.
3- Nurse miss 2 dose antibiotics.
4- Giving fake lab result.
5- Sleeping on duty,
7- Leave duty without endorsement
• The culture of health care in
the past focuses on placing
blame on healthcare providers
whenever there was an error
or bad outcomes occurred.
With this kind of culture, health
care providers were hesitant to
report any errors due to fear of
punishment. As a result such
occurrences were never
To improve reporting of errors,
organizations moved to
blameless culture, however,
this type of culture did not
succeed due to lack of
accountability and the practice
did not promote a learning
environment that promoted
Today, the focus of health care
is patient safety and “Just
Culture” balances the
assessment of systems,
processes and human behavior
when an error or event is
Goal of Just Culture
The goal of a “Just Culture” environment is to design safe
systems that will reduce the opportunity for human
error and capture errors before they reach the patient.
Safe systems should facilitate the staff to make good
decisions and should make it more difficult to make an
error. However, it is up to individuals to manage their
behaviors and choices.
To contribute to the health
of our community through
the provision of quality
services delivered in a
compassionate and cost
effective manner. We
collaborate with others in
the community to improve
the quality of life.
Three basic duties
Duty to produce an outcome. If an individual knows the desired outcome
and should be able to produce it (e.g., safe removal of an inflamed
appendix), failure to do so represents breach of this duty. Did the employee
breach a duty to produce an outcome?
Duty to follow a procedural rule. If the individual knows the proper
procedure and it is possible to follow the rule (e.g., the procedure for
inserting a central venous catheter), failure to do so represents a breach of
this duty. Did the employee breach a duty to follow a procedural rule in a
system designed by the employer?
Duty to avoid causing unjustifiable risk or harm. Breach of this duty
occurs when an individual intentionally harms the patient or acts recklessly.
Did the employee put an organizational interest or value in harm’s way?
Organizations must recognize that humans make mistakes. It is the
behavior choices that must be manage. The behaviors to be
expected when assessing an event are:
Human error -inadvertent action; inadvertently doing other that what
should have been done; slip, lapse, mistake.
At-risk behavior –behavioral choice that increases risk where risk is
not recognized or is mistakenly believed to be justified.
Reckless behavior -behavioral choice to consciously disregard a
substantial and unjustifiable risk.
Why should we put just culture into
• There is a need to learn from accidents
and incidents through safety
investigation so as to take appropriate
action to prevent the repetition of such