How to Incorporate "Just Culture" Into Everyday Acts of Mindfulness
A flash of panic hits me as I look through the medication administrative record and see that a heparin drip had not been ordered for the patient admitted overnight for an un-revascularized ST Elevation Myocardial Infarction (STEMI) awaiting coronary bypass surgery. Frustration momentarily rose inside me. I closed the tab, reopened it and began scrolling again. Rounds were beginning, so I popped my head into the patient's room, relieved to see the heparin drip was running through the IV.
Why wasn't the medication ordered correctly? Who was responsible for ordering it? Was it running all night? Why is the medication not charted? Will the patient suffer a negative outcome? My brow furrowed as I walk into rounds. Who is to blame?
Blame. We all do it. We assign blame freely, rarely wanting to accept it, always trying to deflect it. In medicine, the stakes are high, and we are taught to prioritize precision, attention, and detail. As a result, errors feel monumental, suffocating, and reprehensible. But is this model of blame and fear productive? What if medicine wasn't about blame? Human error is, after all, human. What if we approached medical error with a little less reprehension and a little more understanding?
This approach is not an excuse for error, but a better way to understand it. I was introduced to this idea during my chief year in quality improvement and patient safety. By shifting away from "blame culture" and moving toward "just culture," we can transform the way in which we approach medical fault, error, and how we correct these mistakes.
Just culture in health care means the individual is not at fault for an error, but rather, it recognizes "shared accountability in which organizations are accountable for the systems they have designed and for responding to the behaviors of their employees in a fair and just manner" (Brigham and Women's). The goal of just culture is to ensure more transparency in evaluating the root causes that lead to errors, and ultimately fixing those issue head-on.
As with most things, there is a spectrum of error and a spectrum in how we deal with it. A malicious error may require reproach, whereas an unintentional human error may require coaching, education, or a reevaluation of a part in a system. Three common forms of error and ways to respond to them are heavily diagramed throughout patient safety literature. A quick guide I've found useful to reference, taken from ihs.gov, is shown below:
When contemplating error, it can feel as if just culture can only be applied by a system, for a system. But in a way, it can also be applied in the way in which we evaluate our everyday interactions. What if we hold each other, and ourselves, with a little more mindfulness? By pausing to better understand why an error was made, we remember we are human and that we are all capable of making a mistake.
As the pharmacist reviewed the orders, he realized there was an error in the electronic system which dropped IV medications in transferring a patient from one unit to another. The heparin had been left running as the patient came up from the emergency room to the intensive care unit, though the order was missing. After a reevaluation of our system, and education to the team on communication and indications for medications ordered and administered, we were able to correct the root cause and reduce the chance of a similar error occurring in the future. In doing so, we realized that by refraining from blaming one another for an error, we were able to productively evaluate a problem, seek a solution, promote transparency of problems, and create a more productive and safe work environment for each other and for our patients.
Ultimately, we recognize that communication is often the key to success, and a lack thereof is often our downfall. On days where our workloads are demanding, we can bear to remember that making errors is an inevitable part of a complex system. But by communicating with kindness and mindfulness, we can achieve a cultural change when it comes to identifying errors and seeking solutions. And perhaps, one day, we can even extend this awareness into our lives outside the hospital walls.
This article was authored by Noopur Goyal, MD.