Promote Patient Safety With a Just Culture

Like all health care practitioners, pharmacists have a responsibility to ensure patient safety. Unfortunately, medication errors can and do happen. Pharmacies that punish human error endorse a culture of fear, which may deter reporting and result in increased future risks. Therefore, a shift of organizational mindset toward “just culture” is necessary.

A just culture encourages accountability, learning, and safety by balancing a “responsibility without blame” approach with a learning-oriented culture. This approach fosters trust, encourages error reporting, and leads to system improvements. Just culture promotes patient safety, enhances accountability, and improves the pharmacy work environment.

The History of Just Culture

The concept of just culture originated in the aviation industry in the 1980s where, like pharmacy, mistakes can have catastrophic consequences. To reduce the risk of aviation accidents, a systematic review examined the technology, training, and culture in aviation. The review found that staff members felt unsafe speaking freely about errors without adverse consequences. Therefore, they tended to hide, cover up, or not report certain details.¹ Just culture was expanded into health care in the late 1990s and early 2000s.²

In health care, a blame culture focuses on assigning responsibility and issuing punishment, whereas a just culture seeks to understand the underlying issues that contributed to the error and address those issues to prevent future occurrences.³ In pharmacy, a just culture prioritizes patient safety through the open reporting of errors and near-misses without fear of punishment.

Core Principles

By embracing the core principles of just culture, pharmacies can improve patient outcomes and create a safer, more positive work environment. These principles include recognizing human fallibility, systems thinking, accountability, open communication and reporting, learning and improvement, and psychological safety.

• Recognizing human fallibility: With all processes, human factors often cause mistakes. In pharmacy, this may include dispensing errors. Most medication errors do not result from reckless behavior but from faulty systems and processes. Just culture recognizes this and seeks to acknowledge that these errors can be used to educate others and improve systems to prevent further mistakes.⁴
• Systems thinking: Focusing on identifying and addressing the factors that contribute to errors is a chief concern in a just culture. This is done by analyzing processes, workflows, and environmental influences to make improvements that will prevent the same mistake from recurring.
• Accountability: A just culture is one of shared accountability between the individual and the system(s) responsible for the error. Individuals are held responsible for their actions, particularly when those actions differ from established policies and procedures. Organizations are responsible for creating policies and procedures that provide a safe and supportive environment, supplying resources and training, and proactively addressing system vulnerabilities.⁵
• Open communication and reporting: In a culture of open communication and reporting, staff feel comfortable discussing errors and near misses without fear of blame and punishment. Documentation and reporting of errors and near misses should be used to identify areas for improvement to prevent future occurrences.⁴
• Learning and improvement: Medication error reports can be used to educate others and improve systems to prevent more errors. This is done through systematic analysis to determine trends and patterns, implement preventive measures, and foster a culture of safety emphasizing nonpunitive reporting, open communication, and shared responsibility. These reports are also used to measure and evaluate the success of safety initiatives.⁶
• Psychological safety: Psychological safety refers to an environment in which a person can feel free to express their ideas and concerns openly, ask questions, recognize mistakes, and challenge others without fear of negative consequences. This is crucial to a positive and supportive work environment.⁷

Promoting Just Culture

Establishing a just culture in pharmacy is the first step to improving patient safety. By promoting a just culture, pharmacies can improve communication, encourage transparency, and improve patient outcomes. Written policies and procedures should clearly define expectations for reporting medication errors and near misses. They should also outline the process for addressing human error, at-risk behavior, and reckless behavior.

Pharmacy staff should be educated on the importance of error and near-miss reporting and trained in the proper reporting procedures.⁸ Leaders should also create a work environment in which staff feel free to discuss safety concerns without the threat of retribution.

Uncover the root cause of errors and near misses by analyzing data from error reports, and work with supervisors to implement corrective action to systems and processes based on error reports. Finally, pharmacists and staff should function as role models to coworkers to demonstrate their commitment to a just culture.

Benefits of a Just Culture

A just culture improves patient safety in pharmacy by increasing error reporting, improving system design, and reducing medication errors. It also improves the work environment by boosting staff morale, enhancing communication, and reducing stress and burnout.

REFERENCES

1. Allyn J. Just culture: balancing accountability with quality and safety. Radiological Society of North America. February 18, 2019. Accessed July 10, 2025. https://www.rsna.org/news/2019/february/just-culture-background

2. Geraghty T. Why just culture isn’t sticking. Psych Safety. May 23, 2025. Accessed July 10, 2025. https://psychsafety.com/just-culture/

3. Murray JS, Clifford J, Larson S, Lee JK, Sculli GL. Implementing just culture to improve patient safety. Mil Med.2023;188(7-8):usac115. doi:10.1093/milmed/usac115

4. Rogers E, Griffin E, Carnie W, Melucci J, Weber RJ. A just culture approach to managing medication errors. Hosp Pharm. 2017;52(4):308-315. doi:10.1310/hpj5204-308

5. Eng DM, Schweikart SJ. Why accountability sharing in health care organizational cultures means patients are probably safer. AMA J Ethics. 2020;22(9):E779-E783. doi:10.1001/amajethics.2020.779

6. Al Mutair A, Alhumaid S, Shamsan A, et al. The effective strategies to avoid medication errors and improving reporting systems. Medicines (Basel). 2021;8(9):46. doi:10.3390/medicines8090046

7. Brown W, Santhosh L, Stewart NH, Adamson R, Lee MM. The ABCs of cultivating psychological safety for clinical learner growth. J Grad Med Educ. 2024;16(2):124-127. doi:10.4300/JGME-D-23-00589.1

8. Time for change: respond to patients’ error concerns with empathy and honesty. American Pharmacists Association. Accessed July 10, 2025. https://www.pharmacist.com/Blogs/CEO-Blog/Article/time-for-a-change-respond-to-patientserror-concerns-with-empathy-and-honesty