Overcoming Barriers to a Just Culture

Overcoming barriers to a just culture

There are four major barriers to creating a just culture:

Blame – When things go wrong, humans have a natural tendency to blame the people involved because:

  • Peoples’ actions may be attributed to a personal flaw (attribution bias).
  • Of a mistaken belief that people involved had more control over their actions in the situation than they actually had.

Outcome bias – Humans allow the outcome of a situation to influence the decision about what an appropriate response is for the people involved – generally greater harm will justify more punitive action.

Lack of transparency – Healthcare workers are poorly informed about how their actions will be assessed if they are involved in a patient safety incident, and how a decision will be made regarding the appropriate response to their actions.

Inconsistent assessment processes – Processes used to assess the actions of individuals in the setting of a patient safety incident, and for making decisions about the appropriate response to their actions are inconsistent.

Here are some approaches to overcoming these barriers when things go wrong:


  • Avoid quick judgments.
  • View the situation as an opportunity to identify weaknesses in the system rather than looking for problems with the people involved.
  • Use a systematic approach to gather information about the situation – why people acted the way they did and the factors that may have influenced their actions.
  • Use knowledge of human factors to inform a system view of events and place people’s actions into context.
  • Be aware of, and reduce the influence of bias: hindsight bias, outcome bias, attribution bias.

Outcome bias

  • Assess an individual’s actions without considering the patient’s outcome.
  • Apply a substitution test – what would a person with similar experience have done in the same situation without knowledge of the outcome?
  • Base decisions about the response for the people involved on an assessment of their actions in context, not on the outcome.

Lack of openness

Make available to healthcare workers:

  • The process the organization uses to assess a person’s actions in a patient safety incident situation.
  • How decisions are made about an appropriate response to the actions taken by people involved in patient safety incidents.

Inconsistent assessment processes and decision-making about consequences

  • Use a consistent process to gain insight into why a person did what they did in the context of the situation that existed at the time.
  • Use knowledge of human factors to inform a system view of events and how people’s actions were influenced by the context of the situation.
  • Use a consistent approach to determine what an appropriate response is for the people involved.