Organizations must focus on establishing a culture that supports and advances patient safety. A just culture, as defined by James Reason, is one that supports the discussion of errors so that lessons can be learned from them. Leaders can facilitate a culture of trust that encourages communication across clinical disciplines about issues such as the causes of medical errors and non-punitive approaches to reporting.
A just culture must be experienced by staff in order to sustain self-disclosure of adverse events and holds managers and staff accountable for establishing reliable processes and adhering to them.
*Botwinick L, Bisognano M, Haraden C. Leadership Guide to Patient Safety. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2006.
