Just Culture: An approach to reduce medication mistakes


Natasha Nicol, PharmD, FASHP

Accreditation and Medication Safety
Innovative Delivery Solutions
Cardinal Health

In healthcare and many other industries, we jump to assign blame to an individual when a mistake is made. Then, we turn to technology or education as a solution, possibly firing the mistake-maker as well. This may feel like the right thing to do, but it rarely works.

The "blame game" does not reduce error. In fact, it increases your chance for error! What works in a healthcare setting is a "Just Culture" - an environment where workers trust each other, are rewarded for providing safety information and are clear about their responsibility to make safe behavioral choices. In a nutshell, healthcare professionals must feel safe to report errors, including their own, and administrators must be driven to learn what causes mistakes and how to reduce their number and severity.

A "Just Culture" approach doesn't mean no one ever is punished or even fired. This isn't a "no responsibility" idea. To the contrary, we focus intently on types of error, so that we can correctly understand causes and what actions may be taken to reduce errors.

There are three basic types of errors – and it's a mistake to lump them into one basket:

Human error.

This is a lapse, a pure mistake, an inadvertent action. For example, reading a prescription wrong or not catching a prescription that was written wrong.

At-risk behavior.

Humans tend to drift, to underestimate risk, to ease up, especially when other pressures bear down and shortcuts have been taken in the past without harm. It could be failing to check a prescription after it's been filled by a reliable pharmacy technician or working without a lunch break so your attention is compromised.

Reckless behavior.

This is a choice - like driving drunk. A medication error that results from a conscious disregard for a substantial, unjustified risk must be addressed appropriately.

To reduce errors, you have to understand why they were made. A pharmacist who makes a human error needs to be consoled - not punished. Everyone makes mistakes. In a "Just Culture," we accept this reality and encourage openness and responsibility. When an honest mistake occurs, ask what processes or procedures need to be changed, not what penalty can be applied a particular person.

In contrast, reckless behavior must be punished even if harm doesn't result.In other words, the drunk driver should face consequences, even if no one is killed. Otherwise, the wrong incentives are in place and errors won't be reduced.

Let me tell you a story that illustrates why a "Just Culture" is so essential to reducing errors. I once worked with a hospital system that had issues with nurses not scanning wristbands for positive patient identification when providing medications. The nurses developed many clever workarounds to ensure they still achieved (on paper) the required 98% scanning compliance rate. Nurses were often reprimanded for not scanning wristbands, but no one ever asked why they weren't scanning as required. Well, my team finally did. We discovered the wristband system was nearly impossible to adhere to in the real world. Wristbands wouldn't scan if they got wet, ripped or bent. Nurses weren't scanning because the wristbands wouldn't scan.

Finally, a seasoned nurse risked her job and spoke up. She told us: I'll tell you why I've found multiple workarounds. I want to keep my job and I know my scanning rate has to be close to 98%, so I scan stickers on charts, carts, bedside tables - anything to make it look like I actually scanned the patient. A few months ago I tried scanning my patient and after several failed attempts, I looked over at my patient and saw that she was silently crying. Tears were rolling down her cheeks. When I asked her why she was crying, she told me she was afraid because I obviously had the wrong medicines for her. After that day, I decided I would never trust this system!

If managers had taken the time to ask the nurses why they didn't scan the patients' wristbands, they could have worked to create a better system. Sometimes -- and this can be hard to accept -- our policies and proceduresdon't work. There is always a cause behind both human and at-risk behavior. A leader must not only investigate the system but also determine the causes behind the behavior.

In 2011, the Agency for Healthcare Research and Quality found that only 44% of hospital employees felt comfortable reporting errors. That illustrates how far we have to go in creating a "Just Culture" and, therefore, a safer system for patients. Fear of reporting allows errors to be repeated, sometimes with devastating results. The good news is that treating people based on behavioral choices - rather than outcomes - will provide an eye-opening and liberating way to improve the safety of our health care system.