This accident waiting to happen did happen to the first nurse and her patient. In the first example, further investigation showed that the 2 vials of entirely different medications looked alike in shape, size, color, and print. However, individual practitioners should not be held accountable for mistakes made in a system they cannot control. In only one of these scenarios does an adverse event occur, yet a just culture, with its insistence on a value-based culture and shared accountability, demands that all of these situations be addressed. At a later date, the physician confronts the employee who vehemently denies alcohol abuse. The night nurse supervisor reports to a medical director that the lead respiratory therapist was in the hospital at 4:00 am with alcohol on his breath. Finding a balance between the extremes of punishment and blamelessness is the goal of developing a just culture. However, medical institutions cannot afford a blame-free culture: Some errors do warrant disciplinary action. Similarly, people within the organization must believe that they are obligated to report errors. This process is not possible unless members of the organization remain vigilant and mindful and maintain continuous surveillance. Punishing people without changing the system only perpetuates the problem rather than solving it.Ī patient care system is obligated to collect productive investigative data that can be analyzed and acted upon to improve patient safety. An individual may be at fault, but frequently the system is also at fault. People function within systems designed by an organization. This punitive approach does not solve the problem. One organizational approach has been to seek out errors and identify the responsible individual. In healthcare, errors and accidents result in morbidity and adverse outcomes and sometimes in mortality.

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