Just Culture

A Just Culture Balances the Need to Learn from Mistakes and Take Disciplinary Action

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Engage and Educate a Just Culture  

Patient Safety and the Just Culture: A Primer for Health Care Executives. Marx D. (2001) Prepared for Columbia University under a grant provided by the National Heart, Lung, and Blood Institute.

"To promote a culture in which we learn from our mistakes, organizations must re-evaluate just how their disciplinary system fits into the equation. Disciplining employees in response to honest mistakes does little to improve overall system safety. Yet, mishaps accompanied by intoxication or malicious behavior presents an obvious and valid objection to today's call for blame-free error reporting systems."

Principles of a Fair and Just Culture Institute for Healthcare Improvement

Outcome Engenuity provides training and resources for implementing a just culture.

Execute a Just Culture  

Unsafe Acts Algorithm

Psychologist James Reason constructed this algorithm to help front-line managers determine the culpability or blameworthiness of a single person involved in an incident. The algorithm should be applied to each individual act that contributed to an incident or near- miss. The key questions across the top of the algorithm determine the intent of the individual. More information on how to use this algorithm.