Just Culture-Changing the Environment of Healthcare Delivery

Introduction Given human nature, it is inevitable that people make mistakes, even in the medical laboratory. When a mistake occurs, there are two options to consider. Blame can be assigned to the person who made the mistake, or we can learn how to prevent future errors. An instinctive reaction that focuses on the person caught making the error may be satisfying, however it leaves underlying process flaws unaddressed, creating an opportunity for the same type of error to happen again.

One million people are harmed every year by healthcare errors, including an estimated 120,000 deaths.¹ The single greatest impediment to error prevention is our habit of punishing people for making mistakes.¹ Because traditional disciplinary approaches focus on blame and punishment, few people willingly come forward to report their mistakes. Only 2-3% of major errors are reported through incident reporting systems,¹ leaving the remainder concealed. In order to improve the safety of healthcare by analyzing near-miss and adverse events, we must first increase the willingness of individuals to report their errors. Most laboratory scientists and other healthcare personnel—and much of the public—regard errors by healthcare providers as evidence of personal carelessness. As a result, individuals only report what cannot be concealed. This is not an effective solution to preventing human error.