Improving Patient Safety Means Fixing the System, Creating a Just Culture, and Not Blaming the Individual: Celebrating National Patient Safety Awareness Week 2023

By Michael Wong, JD (Founder & Executive Director, Physician-Patient Alliance for Health & Safety)

National Patient Safety Awareness Week Recognizes that Systemic Errors are Not Personal Errors

When I introduce myself as an advocate trying to improve patient safety, I often get asked whether this means that I go after “bad” doctors and nurses. To put this question in a legal perspective, I’m being asked whether the “bad” doctor or nurse was negligent and has committed medical malpractice. 

This is a good question, particularly for me, as I am a lawyer and the question of medical malpractice is a legal one.

However, I answer this question of “bad” doctors and nurses by saying that an adverse event or death may have occurred when no “error” has been made. In other words, procedures were followed, but a bad outcome nonetheless ensued.

For example, the goal of preventing systemic errors led to the development of checklists, such as the PCS Safety Checklist. 

The goal of the PCA Safety Checklist is to standardize the process whenever a patient is placed on a patient-controlled analgesia pump (“PCA Pump”). Now, for those unfamiliar with PCA Pumps, they provide the patient with a physician-prescribed amount of analgesia when the patient pushes the button on the pump. 

PCA Pump seems safe enough – after all, it is just a mechanical device doing what it is programmed to do. However, it is estimated that between 600,000 to 2 million events per year could involve a PCA Pump.

Patient Safety Awareness Week - PCA Pump

Now, don’t misunderstand me – of course, an adverse event or death may occur because of negligence or an error caused intentionally or unintentionally by a person.

But, what happens when a person, say a nurse, is just following what the doctor said to do and, as a result, an adverse event or death ensued? Should the nurse be held liable for doing what the doctor ordered?

In the case of Connette v. Charlotte-Mecklenburg Hospital Authority, the facts surrounding that case were:

During the preparation of an “ablation procedure” on three-year-old Amaya Gullatte’s heart and shortly after she was induced with the anesthetic sevoflurane Amaya went into cardiac arrest, resulting in the onset of permanent brain damage, cerebral palsy, and profound developmental delay. 

In what may on its surface appear to be a travesty of justice, the North Carolina Supreme Court reversed the opinion rendered by the court of appeals affirming the trial court’s judgment and concluded that the nurse could be held legally liable even though the nurse was only following doctor’s orders. In so doing, the North Carolina Supreme Court overturned Byrd v. Marion General Hospital, the 90-year-old precedent that protects nurses when working under a doctor’s supervision.

According to Danielle Miller, RN, business advisor, and medical consultant, ‘the new ruling simply holds nurses to an already existing, appropriate standard of care. The court rules that even when a nurse is carrying out duties under a doctor’s orders, a nurse may be held liable for medical malpractice “in the event that the registered nurse is found to have breached the applicable professional standard of care,” says Miller.’

In other words, someone can be found liable even if they were following the orders of a superior if that person’s actions were in breach of the professional standard of care that their peers follow.

However, when we focus on blaming individuals is that people will not report problems and issues, for fear of any reprisals; and if we are not aware of incidents, then fixes cannot be made. As HealthManagement reports:

Sadly, one pattern that also continues is a culture of blame and denial (CoBD). Culture is what you say and do on a daily basis. How errors are analysed, discussed and acted upon influences the culture of an organisation. Human error factors can cause negative patient outcomes, but they are not isolated as a cause of harm. Processes, policies and system failures have greater influence over patient outcomes than individuals. Leaders who focus solely on the individual human errors reinforce a CoBD, in which employees tend to not want to be singled out or disciplined. This creates a cycle of employee unwillingness to elevate issues or failures that need addressing.

Improving patient safety entails creating a “Just Culture.” In their article “Implementing Just Culture to Improve Patient Safety,” John S Murray, PhD, MPH, MSGH, RN, CPNP-PC, CS, FAAN, USAF, NC (Ret.) and his colleagues explain why a just culture in healthcare is so needed:

While the exact number of deaths in the United States as a result of medical errors remains controversial, what is clear is that underreporting is a common and challenging impediment to improving patient safety. Evidence shows that one of the most significant reasons for underreporting is the fear of the negative consequences associated with reporting. In fact, fear is the most reported reason for underreporting worldwide. In the United States, some health care institutions are on the journey to becoming high-reliability organizations (HROs). HROs provide consistent excellence in quality and safety, over extended periods of time, reducing patient harm. Improving patient safety requires that HROs strive to ensure the culture of the organization is trusting and just.5 In a trusting and “just culture,” adverse events are recognized as valuable opportunities to understand contributing factors and learn rather than immediately assign blame. Moving away from a blame culture is a paradigm shift for many health care organizations.

Because a Just Culture shares responsibility for unintended consequences, patients are safer in a Just Culture than in one that looks for individual fault. In their article, “Why Accountability Sharing in Health Care Organizational Cultures Means Patients Are Probably Safer,” Deborah M. Eng, MS, MA and Scott J. Schweikart, JD, MBE describe this as follows:

A just culture perspective suggests that responding punitively to those who err should be reserved for those who have willfully and irremediably caused harm, because punishment creates blame-based workplace cultures that deter error reporting, which makes patients less safe.

National Patient Safety Awareness Week and The Need for Just Culture to Reduce Adverse Events and Patient Deaths

Major medical organizations are in favor of implementing a Just Culture to improve patient safety and quality of patient care. For example, the American Nurses Association issued a position statement for a Just Culture, stating:

As an alternative to a punitive system, application of the Just Culture model, which has been widely used in the aviation industry, seeks to create an environment that encourages individuals to report mistakes so that the precursors to errors can be better understood in order to fix the system issues. The term “Just Culture” was first used in a 2001 report by David Marx (Marx, 2001), a report which popularized the term in the patient safety lexicon (Agency for Healthcare Research and Quality, n.d.). Traditionally, healthcare’s culture has held individuals accountable for all errors or mishaps that befall patients under their care. By contrast, a Just Culture recognizes that individual practitioners should not be held accountable for system failings over which Just Culture they have no control. A Just Culture also recognizes many individual or “active” errors represent predictable interactions between human operators and the systems in which they work. However, in contrast to a culture that touts “no blame” as its governing principle, a Just Culture does not tolerate conscious disregard of clear risks to patients or gross misconduct (e.g., falsifying a record, performing professional duties while intoxicated). 

So, in celebration of National Patient Safety Week 2023, let’s implement Just Cultures in all of our healthcare facilities. Let’s think of patient safety this week and every week.

Patient Safety Awareness Week



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