JUST CULTURE AND REPORTING MEDICATION ERRORS

To encourage pharmacists to exert leadership in establishing a just culture in their workplaces and a nonpunitive systems approach to addressing medication errors while supporting a nonthreatening reporting environment to encourage pharmacy staff and others to report actual and potential medication errors in a timely manner; further,

To provide leadership in supporting a single, comprehensive, hospital- or health-system-specific medication error reporting program that (1) fosters a confidential, nonthreatening, and nonpunitive environment for the submission of medication error reports; (2) receives and analyzes these confidential reports to identify system-based causes of medication errors or potential errors; and (3) recommends and disseminates error prevention strategies; further,

To provide leadership in encouraging the participation of all stakeholders in the reporting of medication errors to this program.

(Note: A just culture is one that has a clear and transparent process for evaluating errors and separating events arising from flawed system design or inadvertent human error from those caused by reckless behavior, defined as a behavioral choice to consciously disregard what is known to be a substantial or unjustifiable risk.)

Rationale

“Just culture” is an approach to medical error management that recognizes individual accountability for behavioral choices that compromise safety. The concept of “just culture” was first introduced by Sidney Dekker, a pilot and systems engineer, who recommended a different approach to the view that management of medical error should take a strict systems approach with a “no blame” attitude regarding individual accountability. David Marx, a lawyer and engineer, added additional background and recommendations, including criteria for determining whether error is “human” (i.e., inadvertent and unintended) or the result of behavioral choices that introduce risk. 

“Just culture” differs from the “no blame” approach in two ways: (1) intentional actions that introduce risk or lead to error are acknowledged, and (2) an algorithm or criteria are used to determine the type of corrective action that should be taken (e.g., coaching or disciplinary action). “Just culture” has come to be accepted over the “no blame” approach because it allows the safety and health care community to address what Dekker and Marx characterize as at-risk and reckless behavior as causes of error.