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Pharmacy Times
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In pharmacy, this model encourages taking responsibility and the open reporting of errors and near-misses without fear of punishment.
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.
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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 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
Kathleen Kenny, PharmD, RPh, earned her doctoral degree from the University of Colorado Health Sciences Center. She has more than 30 years of experience as a community pharmacist and works as a clinical medical writer based out of Albuquerque, New Mexico.
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.
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.
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.
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.
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