Christian Dankers, MD
Deborah Mulloy, PhD, RN

A major safety event just happened in your area and you want to better understand the systems and human factors that contributed to it in order to reduce the safety risk going forward.

Brigham and Women’s Hospital has committed to using the principles of Just Culture to better understand what systems and behaviors may contribute to these types of events. Using principles of Just Culture is an approach that helps to trouble-shoot systems issues and manage any contributory behaviors in a fair, just and collaborative way.  Safety events are often complicated, with lots of people involved and multiple different decision points. So where to start? Perhaps it would help to run through the event with one of the Just Culture advisors.

Just Culture advisors are a resource when you are seeking to apply Just Culture tools in your day-to-day work. Appointed by hospital and department leaders, Just Culture advisors receive additional training in the application of Just Culture concepts and continue to develop these skills at monthly Just Culture Advisory Committee meetings. Approximately 80 individuals from across BWH have been trained as advisors, and they will become our institutional Just Culture coaches, serving as a resource for staff and guiding overall strategy for the integration of Just Culture principles at BWH. While it will take time for us all to become comfortable applying these concepts, the hospital is committed to developing this internal expertise.

The goal of Just Culture at BWH is to enhance our culture of safety. A strong culture of safety is one in which staff are curious about why errors occur, are encouraged to speak up about safety concerns and feel safe doing so, without fear of punishment. The key to nurturing this environment is to support the interactions of managers and their staff as they talk about error. This is the role of the Just Culture advisors.

If you have a case that you would like to discuss, please do not hesitate to reach out to us.  Email cdankers@partners.org or dmulloy1@partners.org, and we would be glad to help out in whatever way we can.