People in the shape of scales

Just Culture

Just culture holds both individuals and organizations accountable for patient safety by managing human behavior and designing safe systems of care. People work within systems created by an organization. Errors can occur when systems are ineffective or poorly designed. In such a case, the organization is responsible for finding out why it is not working and then creating a better system. Errors can also occur due to individual failures (ex. person who has the knowledge, resources, and/or skills to do the right thing and they make an unsafe choice). A just culture sets limits beyond reminders, coaching, and mentoring to include disciplinary action for reckless behavior.

In order to create better systems of care, errors and near misses must be reported to learn from them. Establishing a non-punitive environment helps to encourage reporting and is essential in developing a culture of safety. Errors and near misses will not be reported if there is a fear of punishment. Just culture aims to create an environment in which there is a balance of trust, reporting of safety concerns, and individual accountability (Fondahn, 2016).

Consider the following example within the context of just culture:

The Chatsworth train collision occurred on the afternoon of Friday, September 12, 2008 at the beginning of the evening commute in a high-density travel corridor. This mass casualty accident brought a massive emergency response by the city and county of Los Angeles, taxing resources to the breaking point. Twenty-five people died, and many survivors were hospitalized for an extended period. The Metrolink train company was exposed to more than $200 million in liability judgments.

Investigations revealed that the train engineer did not obey a signal to not enter a single-track segment (designated as such because of oncoming train traffic). The Metrolink passenger train and a freight train were headed toward one another, both moving at a speed of 40 miles per hour. The engineer of the freight train engaged his air brake 2 seconds before impact, while the engineer of the passenger train did not engage his brake. Further investigation revealed that the engineer in the commuter train had a habit of text messaging while operating the train and had been warned about this policy violation. Nevertheless, his cell phone history (delivered under subpoena) showed 2 text messages sent shortly before impact. A spokeswoman for the train company admitted the strong likelihood of operator error… (Boysen, 2013, p. 401)

In a just culture, the event is investigated to differentiate human error (ex. occurring from not being in the moment and paying attention), risky behavior (ex. taking short-cuts), and reckless behavior (ex. disregarding required safety steps) (Agency for Healthcare Research and Quality, 2019). This example demonstrates a need for individual accountability related to reckless behavior in disregard of the policy. In addition, other areas for system improvement would also be explored.

Overall, there is a fine line between a no-blame approach and individual accountability. A just culture takes this into account by focusing on identifying and fixing systems issues that encourage workers to participate in unsafe behaviors and holds individuals accountable when appropriate (Agency for Healthcare Research and Quality, 2019). In addition, this is done from a learning perspective- learning from safety events to promote continuous improvement and prevent similar occurrences from recurring.

*If this article interests you, you may also enjoy my book titled: Obstetric and Neonatal Quality and Safety (C-ONQS) Study Guide: A Practical Resource for Perinatal Nurses, available on amazon: Amazon_obneonatalstudyguide


Agency for Healthcare Research and Quality. (2019). Culture of Safety. Retrieved from 

Boysen P. G., 2nd (2013). Just culture: a foundation for balanced accountability and patient safety. The Ochsner Journal, 13(3), 400–406.

Fondahn, E., Lane, M., & Vannucci, A. (2016). The Washington Manual of patient safety and quality improvement. Wolters Kluwer.


Copyright by Jeanette Zocco RNC-OB, C-EFM, C-ONQS

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