Creating a “just culture”: More work to be done

Institute of Medicine (US) Committee on Quality of Health Care in America, Kohn LT Corrigan JM Donaldson MS (eds). To err is human: Building a safer health system. Washington, DC: National Academies Press (US), 2000.

Reason JT Carthey J de Leval MR Diagnosing “vulnerable system syndrome”: An essential prerequisite to effective risk management. Qual Health Care 2001; 10: ii21–ii25.

Nottingham J . Medical errors. Perhaps blame-free culture is needed in NHS to reduce errors. Br Med J 2001; 322: 1422.

McNeill PM Walton M . Medical harm and the consequences of error for doctors. Med J Aust 2002; 176: 222–225.

Wachter RM Pronovost PJ . Balancing “no blame” with accountability in patient safety. N Engl J Med 2009; 361: 1401–1406.

Reis-Dennis S . What ‘just culture’ doesn't understand about just punishment. J Med Ethics 2018; 44: 739–742.

Tigard DW . Taking the blame: Appropriate responses to medical error. J Med Ethics 2019; 45: 101–105.

Parker J Davies B . No blame no gain? From a no blame culture to a responsibility culture in medicine. J Appl Philos 2020; 37: 646–660.

Reason J . Managing the risks of organizational accidents. Ashgate Publishing, 1997.

Marx D . Patient safety and the “just culture”: A primer for health care executives. New York: Columbia University, 2001.

Morris ZS Wooding S Grant J . The answer is 17 years, what is the question: Understanding time lags in translational research. J R Soc Med 2011; 104: 510–520.

Dekker SW Hugh TB . Balancing “no blame” with accountability in patient safety. N Engl J Med 2010; 362: 275–276. author reply 275-6.

Dekker SWA Nyce JM . Just culture: “evidence,” power and algorithms. J Hosp Admin 2013; 2: 73–78.

Gorini A Miglioretti M Pravettoni G . A new perspective on blame culture: An experimental study. J Eval Clin Pract 2012; 18: 671–675.

Murray JS Clifford J Larson S , et al. Implementing just culture to improve patient safety. Mil Med 2022: usac115. 10.1093/milmed/usac115.

Just Culture Decision Support Tool. VA National Center for Patient Safety. https://www.patientsafety.va.gov/docs/Just-Culture-Decision-Support-Tool-2022.pdf (2022, accessed 21 March 2023).

Okuyama JHH Galvao TF Silva MT . Healthcare professional's perception of patient safety measured by the hospital survey on patient safety culture: A systematic review and meta-analysis. Sci World J 2018; 2018: 9156301.

Aljabari S Kadhim Z . Common barriers to reporting medical errors. Sci World J 2021; 2021: 6494889.

Panagioti M Panagioti M Khan K , et al. Prevalence, severity, and nature of preventable patient harm across medical care settings: Systematic review and meta-analysis. Br Med J 2019; 366: l4185.

World Health Organization. Patient safety: Global action on patient safety: Report by the Director-General. In: Seventy-second World Health Assembly. Geneva: World Health Organization, p. 7. https://apps.who.int/gb/ebwha/pdf_files/WHA72/A72_26-en.pdf (2019, accessed 21 March 2023).

Petschonek S Burlison J Cross C , et al. Development of the just culture assessment tool: Measuring the perceptions of health-care professionals in hospitals. J Patient Saf 2013; 9: 190–197.

Weiner BJ Hobgood C Lewis MA . The meaning of justice in safety incident reporting. Soc Sci Med 2008; 66: 403–413.

Lee JH Benoit A Aubert A , et al. Risk mapping in community pharmacies. J Patient Saf Risk Manag 2023; 28(2): 59–67.

Alolayyan M Hijazi B Jalaileh RA . The association of patient safety culture with patient satisfaction: The role of the pharmacist’s performance. J Patient Saf Risk Manag 2023; 28(2): 68–77.

Azilagbetor DM Jawara M . Improving patient safety: Did we learn from the story of Jean-Pierre Adams? J Patient Saf Risk Manag 2023; 28(2): 89–94.

Heller J . Catch-22. New York: Simon and Schuster, 1961.