Just culture, a neglected culture in health system

Abstract

Patient safety incidents have emerged as a significant global concern, impacting healthcare systems worldwide, as highlighted by the WHO's report of 134 million adverse events annually in hospitals. Healthcare professionals often hesitate to report such incidents due to stigma and the fear of criticism. To combat this, the implementation of a "no-blame culture," introduced by James Reason in 1997, has gained traction, evolving into the concept of a just culture—an environment fostering open discussion of safety-related information without fear of retribution. This approach facilitates an effective incident reporting system and enhances staff capabilities while building organizational trust and accountability. Previous research indicates that adopting a just culture can lead to increased reporting of patient safety incidents, enabling healthcare staff to learn from them, thus reducing the likelihood of future incidents. It’s critical to recognize that a just culture focuses on systemic issues rather than individual blame, which encourages reporting and corrective action. However, this culture is not yet widespread due to misunderstandings. Healthcare leaders and policymakers are urged to promote a just culture by implementing strategies like transparent reporting mechanisms, clear error identification processes, exemplary leadership, and ongoing assessments, ultimately prioritizing patient safety.