This article is reprinted from the Speak Out Now healthcare newsletter at Kaiser and Highland Hospitals in Oakland, CA.
When there is an incident involving a patient, such as a medication error or a patient fall, management conducts an investigation to see what went wrong and who to blame. Healthcare facilities often state that they run these investigations under the premise of “Just Culture” — a process which is supposed to focus on systemic problems that led to the patient incident, rather than just seeking out a single nurse to discipline. “Just Culture” is meant to encourage open reporting of errors, to help the organization identify these systemic errors and prevent them from reoccurring.
Unfortunately, however, management instead often promotes “Just Culture” in their policies, but in practice punishes and disciplines nurses for human errors. Instead of focusing on why an error occurred, such as short staffing or broken equipment, it is easier and cheaper for management to blame a single nurse. Sadly this leads to less reporting of errors, low staff morale, and a missed opportunity for the organization to learn from its mistakes and actually support its staff.
We need to hold management accountable to practice what they preach. We need real Just Culture, where systemic problems are recognized and remedied, rather than blaming staff for struggling to perform to the highest standard when management leaves them without the tools and resources to do so.
Click here to read the article printed in the 07-02-25 Healthcare Newsletter
