Healthcare workers try to provide the best patient care they can every day. But no matter how careful they are, there is always the possibility that something might go wrong. Humans are not perfect – errors can happen despite our best efforts to be careful. When something goes wrong with care delivery, how we communicate about what happened can either support or undermine a just culture.

To support a just culture, when something goes wrong with care delivery include the following messages in communication about the incident:

• The patients and their families and the healthcare workers involved are being supported and treated with compassion and dignity. This is devastating for everyone involved.
• We are committed to learning from situations where care is not as we wished or intended it to be. Looking for someone or something to blame gets in the way of learning and improving.
• In every situation there are many factors that influence the decisions people make and the actions they take. When something goes wrong with patient care, the decisions and actions of the people involved are considered in light of what was happening at the time.
• We are collecting information about the facts of what happened and the different factors that influenced the decisions and actions of the people involved. We use a systematic and fair process to understand what happened and avoid common sources of bias in interpreting the facts.
• We believe our healthcare providers are our greatest resource. We know they are committed to providing outstanding patient care. We are committed to understanding all the circumstances and context of the situation before making any judgments about their decisions or actions. Healthcare providers also suffer after being involved in situations where care didn’t go as intended, and they deserve our support, compassion and care.
• People will be held accountable for their actions, but not for factors in the situation that were beyond their control. A range of responses to their actions is possible. The decision about what response is appropriate will be based on what happened, not on the patient‘s outcome.
• Healthcare workers are human and despite their best efforts to provide safe patient care they can still make errors. It is extremely rare for a healthcare worker to deliberately harm someone they are caring for.
• The organization is committed to learning from this situation and making changes to improve system safety for our patients.

Example

Here is an example of communication that demonstrates a commitment to a just culture. The author acknowledges the reality that care is not always perfect. Situations when care is not experienced as we wish it to be are seen as a chance to learn and improve rather than looking for an opportunity to blame.

Opinion: In health care, learning from errors is a painful but healing process