Despite our best efforts, humans still aren’t perfect, nor are the systems we create. Even the most careful nurse, detail-oriented physician, or conscientious transporter can make mistakes, but in health care, mistakes can have serious consequences. Whether an error makes it all the way to the patient or is caught along the way, when patient safety is compromised, it needs to be addressed. But how?
A hospital’s response to safety events can run on a spectrum from individual punishments — “Off with their head! This is their fault.” — to laissez-faire blamelessness — “Hospitals are inherently complex and unsafe, so what are we supposed to do?” — but Pennsylvania Hospital has chosen to pursue a balanced approach that avoids the pitfalls of those extremes. Fair and Just Culture is a workplace culture built on trust and transparency. It empowers clinical and non-clinical staff to report safety concerns and errors without fear, and it holds both staff and the hospital’s systems accountable by responding to safety events with reasonable, learning-based consequences. The result: broken systems are fixed, staff are given the tools to prevent future harm, and patient outcomes are improved.
Starting with the Basics
In February and March, executive leadership and PAH directors and managers took part in Fair and Just Culture trainings led by Patty Harris, director of Patient Safety and Process Improvement and co-lead of PAH’s Fair and Just Culture Committee, and Maureen Ann Frye, MSN, CRNP, a national patient safety and quality leader and former senior director of the Center for Patient Safety and Healthcare Quality at Abington Jefferson Health. Each session covered extensive ground and opened up dialogues about thoughtfully responding to safety events, dismantling punitive attitudes, and dissecting case studies to learn from other health systems’ experiences.
Participants also learned to identify human errors — inadvertent mistakes, risky behaviors, or consciously reckless choices — and system errors. For example, Frye presented the case of a hypothetical nurse who accidentally administered ten times the dose of a patient’s medication; she had cross-checked the order with the patient’s information, but she was exhausted after a long day on a short-staffed unit, and the vials looked the same. Though the group agreed the nurse in the scenario should receive coaching, the underlying issue was the vials’ nearly identical appearance — a system error that needed to be corrected to protect patient safety.
“It’s important for staff to know their leaders will treat them fairly after an event, no matter the outcome. The question isn’t, ‘How could they screw this up?’ but ‘Why did it make sense for them at the time to do what they did?’ For management, this is the moment of truth — it’s their responsibility to differentiate between unintended human errors, system issues, and unsafe behavioral choices,” Frye said.
Ditching the Blame Game
At the heart of Fair and Just Culture is the rejection of both automatic disciplinary action and a blame-free culture. While PAH champions respect, empathy, and effective communication between colleagues, it’s easy to assign blame when something goes wrong, or to just assume everyone had good intentions. However, disciplining staff without assessing organizational issues perpetuates problems, allows systems to erode, and can lead staff to be fearful or skeptical of reporting errors. Absolving blame entirely also undermines potential process improvement and fails to address reckless or non-compliant staff. The key is creating a process that is more investigative than interrogative.
“As leaders and role models of accountability, you need to get the facts before rushing to judgment. Count to five. Listen actively. Address all parts of the story, all the roles people played, and all the system breakdowns involved before coming to conclusions, and then respond in a fair and just way,” Frye said. “People will make mistakes, but why wait for further harm to fix what needs fixing or to coach who needs coaching?”
With Fair and Just Culture training under their belts, PAH’s managers and directors are prepared to treat errors like opportunities to identify patterns, tackle systemic problems, create intuitive work processes, and coach or retrain staff, and they plan to share these takeaways with their teams.
“We are excited to have taken such a large step in our high reliability journey. Although we are in the early phases of creating a Fair and Just Culture, we can already feel and hear the shift in our thinking about errors,” Harris said. “I look forward to our next months and years as leadership, providers, and staff work together to learn and grow from understanding the causes of our near-misses and errors.”