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Patients’ Safety in the United States


People make errors that result in accidents, adverse health outcomes, and mortality. For a long time, the healthcare system has been organized in a manner that errors in the health organizations are blamed on the individuals (Marx, 2001). As a result, a healthcare practitioner is held accountable and punished for mistakes that happen in the areas of duty. The punitive approach has not solved the errors in healthcare institutions. The approach does not take into consideration the systematic issues that may have contributed to a medical error. Kohn, Corrigan, and Donaldson (2000) noted that an individual may be responsible for the error but many times, the leadership of the health organization overlooks the faults within the system. The consequence is punishing the individual without changing the system. The failure to increase the safety of patients by changing the system does guarantee the reduction of errors. The following paper analyzes the concept of just culture.

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Just Culture

The development of the just culture concept dates back to 1997 when John Reason pointed out that just culture is essential in the creation of an environment that enhances trust. Trust within the healthcare setting helps in the provision of information that touches on safety. In the healthcare setting, the term just culture was first incorporated in a health report in 2001. The aim of just culture is to address the punitive approach in the health care system and to determine whether the punitive system solves human errors or it hurts the safety of health efforts. The concept of just culture acknowledges that punitive measures result in hindering the information that is needed to solve the faulty systems (Marx, 2001). The system that does not encourage just culture prevents healthcare practitioners from correcting their mistakes. Thus, just culture is based on the fact that health caregivers should not be held responsible for mistakes that result due to system failures. However, this does not tolerate the conscious disregard of risks that are clear.

In the U.S, the Institute of Medicine (IOM) stated that patients should not be harmed by the health care system that is supposed to heal them (Kohn et al., 2000). This led to the acknowledgment of an approach to remedy the medical errors in the health system. In the analysis of the medical errors, it was found that most medical errors do not occur due to personal negligence but are caused by faults in the healthcare system. Therefore, common mistakes in healthcare can be prevented by designing a safer health system. This should be carried out at the various levels of health care in order to make it easier for health professionals to do the right thing. A safer healthcare system encourages information sharing and prevents people from repeating the same errors.

Transformational Leadership

Studies have shown that medical errors are few in hospitals that have embraced a culture of safety that is based on inclusive leadership (McFadden, Henagan & Gowen, 2009). Nurses operate in an environment that has been changing drastically. Due to the changes, there is a need for a leadership model that responds to the changes. The transformational model provides a platform that encourages adaptive and flexible leadership in which nurses and other health practitioners can share information. Transformational leadership creates a working environment of shared responsibilities that motivates people to have higher ideals and moral values. In the transformational leadership model, the leader encourages a participatory approach to solve healthcare issues instead of imposing responsibility on individuals.

The transformational leadership model is designed on the basis of idealized influence and individual consideration; hence, the creation of a just culture. This is achieved by encouraging a sense of advocacy in which the leaders support staff and patients. The leadership model makes nurses be at ease when reporting problems. It also enhances the sense of accountability for the improvement of the system as there is a platform for sharing ideas.

Classes of Human Behavior

Human behaviors have an effect on the healthcare system. According to Congress on Nursing Practice and Economics (2010), the behaviors adopted by nurses can increase or reduce medical errors. The common classes of human behavior include accountability, intimidation, and disruptive behaviors. Accountability behavior creates a sense of belonging to the system and thus promotes the adoption of safer healthy practices. On the other hand, Congress on Nursing Practice and Economics (2010) noted that intimidation and disruptive behaviors increase medical errors. The disruptive behaviors do not encourage professional work environments. In order to promote a just culture, healthcare organizations must create environments that encourage positive work behaviors.


The intimidation behaviors discourage teamwork and hinder effective communication among the health workers. As a result, the expected teamwork is negated. Marx (2001) noted that the safety and quality of patient care are influenced by collaboration between the staff members and the leadership. An example of an incident that I experienced related to intimidation behavior. It involved a trainee nurse who accidentally bathed a newborn with very hot water that burned the infant. After the error, the management of the hospital did not take responsibility but blamed the nurse for not being careful. The nurse was suspended, and the management of the hospital did not take time to investigate what led to the error.

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I felt unsatisfied with how the case was handled. This is because the blame was purely placed on the nurse. The management failed to investigate the systematic errors that led to the nurse bathing the baby using the water above the normal temperatures. In reality, if there were checks in the system to ensure that water for bathing the newborns was tested for the right temperature before entering the wards it could avoid future errors. In a just culture approach, the management could have taken time to investigate the issues that led to the error. This could also encourage the trainee nurse to provide information on what happened. The result would have resulted in a clear analysis of the systems and identification of measures that can be taken to avoid a repeat of such an error. The issue was not solved amicably, and it is bound to happen again.


Congress on Nursing Practice and Economics. (2010). Just culture. Silver Spring: American Nurses Association.

Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (2000). To err is human: building a Safer Health System. Washington, DC: National Academies Press.

Marx, D. (2001). Patient Safety and the Just Culture: A Primer for Health Care Executives. New York, NY: Columbia University.

McFadden, K., Henagan, S., & Gowen, C. (2009).The patient safety chain: Transformational leadership’s effect on patient safety culture, initiatives, and outcomes. Journal of Operations Management, 27 (1), 390-404.

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