The Just Culture Taxonomy

The vast majority of adverse events, near misses, and deviations from standards of care in healthcare fall to the left of the orange line. As Don Berwick is quoted as saying, "“Most serious medical errors are committed by competent, caring people doing what other competent, caring people would do.”  Too often, events that fall to the left of the line are misclassified by healthcare leaders as Reckless Behavior, and punitive action is the primary outcome. Over time, punitive action has a complete inability to improve patient safety, and in fact probably reduces it for several reasons, including: causing a culture that hides "error," the loss of institutional memory by terminating the folks who have learned the most from past events, and causing the organization to have higher turnover with resulting less experienced staff, and (most importantly) suppressing the organizations ability to look at the events in adequate enough depth to see the real latent hazards which could be reduced with systems solutions (once the blame is laid, the inquiry is satisfied). Integrating the Just Culture approach into an organization is a great first step for organizations trying to move away from the "name, blame, shame, and train" culture that is so deeply entrenched at the frontlines of so many healthcare organizations.

This chart is adapted from the work of David Marx and Colleagues (www.JustCulture.org).

Contact: Terry Fairbanks