Pharmacies Encourage Just Culture Philosophy--June 2009

If polled, most pharmacists would be hard-pressed to see a correlation between pharmacy and aviation. Although it may seem like an odd pairing, the National Association of Boards of Pharmacy is trying to come up with a system to encourage pharmacists to self-report their own mistakes and the ones they catch in a nonpunitive way-similar to the aviation industry's methods.

The thinking behind self-reporting is called "just culture," said New Jersey Mayor Richard Palombo, RPh, who serves on the association's executive committee. The school of thought is that just culture accepts that individuals are going to make errors but addresses the mistakes by finding out where system breakdowns occur. "The idea is errors are caused by the system and the environment," he said.

Palombo explained that the aviation industry has standards for nonpunitive reporting by identifying their near-misses. They cull the data and there is outreach to all the airlines about how to fix the problem. Pharmacies are trying to get away from the culture of punishment to encourage self-reporting of errors, even those little mistakes the pharmacists caught before the prescription left the pharmacy. "Nobody wants to incriminate themselves. But we need a record kept of errors and how you address them," said Palombo.

David Marx, chief executive officer of Outcome Engineering in Plano, Texas, said that just culture does not excuse reckless behavior, but accepts human fallibility as a part of life. His company advises organizations about how to create a just culture. "We want to console the human error, coach at-risk behavior, and punish the reckless. The model says we're sorry you made a mistake, but we want to know how you got there."

The Minnesota Board of Pharmacy has adopted an error reporting system using just culture. Several hospitals also are encouraging clinicians to come forward without the risk of severe punishment, said Marx.