January 23, 2017

Error Investigations Under a Just Culture

Over the past few months, we’ve been talking about just culture this and just culture that. We’ve told you what it is, why you need it and who should implement it. But one of the things we haven’t touched on is what you can expect from a just culture, especially when you’re conducting an error investigation.

Even with a just culture, a simple error investigation isn’t always so simple; it’s not always as cut and dry as figuring out what happened and responding. Error investigations under a just culture will require a group of insightful leaders who can look beyond their normal bias to understand the error, respond appropriately, and move forward, stronger than before.

If you’ve already implemented a just culture and are preparing for your first error investigation, here are a few things to keep in mind.

You’ll need to look beyond your own bias. 

It’s easy to sit in the present moment and say, “Well, how could they make that mistake? Why wouldn’t they just…”

What’s that thing they say about hindsight being 20/20? And although your hindsight will make it obvious how easily the error could have been avoided, you need to look beyond that to understand exactly what the individual was thinking at that point in time.

The process isn’t always to blame.

When there’s an error, we’re tempted to blame it on the process. “Well, maybe if we did things this way instead, this wouldn’t have happened.”

But here’s the harsh reality: Good processes can lead to bad outcomes, and bad processes can lead to good outcomes.

In most cases, the process isn’t to blame for human error.

Understand that human memory is limited.

Our every movement isn’t videotaped, which means, when it comes to errors in healthcare, we often have to rely purely on human memory. Which is very limited. Not only can our brains play tricks on us as we replay the same moment over and over, but as time goes on, it becomes more and more difficult to separate what actually happened…and what we’ve made ourselves believe happened. By understanding this, we can communicate more openly, with less judgment, and get to the root of what really happened.


Remember: The best way to deal with error investigations under a just culture is to focus on open-ended questions and maintain mutual respect. Do your best to make the individual feel comfortable and heard, and try to understand the error as it happened from their perspective.

Stay tuned for more articles on just culture in our upcoming newsletters!

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