According to the US Institute of Medicine, “the biggest challenge to moving toward a safer health system is changing the culture from one of blaming individuals for errors to one in which errors are treated not as personal failures, but as opportunities to improve the system and prevent harm.”
Unfortunately, a ‘blame and shame’ approach to mistake-making prevails across healthcare professions. Because individuals are often blamed for the shortcomings of the system in which they work everyday, stigma and fear prevent open communication about mistakes, root-causes remain invisible, and future patients may be harmed by a preventable recurrence. In a just and safety culture, learning from safety incidents and close calls is supported by destigmatizing errors, recognizing that systems fail more often than people, and that we are all accountable for safety.
Your pharmacy can use the following resources to support introducing or improving a workplace culture that prioritizes system improvements, patient safety, and just accountability.
1. Community Pharmacy Safety Culture Toolkit
College of Pharmacists of Manitoba (free)
Pharmacy teams can use the Community Pharmacy Safety Culture Toolkit (CPSCT) to work toward a just-and-safe approach to preventing and dealing with medication incidents and to promote local, team-based solutions for improving patient safety. The CPSCT outlines key concepts and resources on safety culture including
- Measurement and monitoring of safety culture
- Leadership
- Teamwork and communication
- Psychological safety
- Transparency and accountability
- Disclosing medication incidents to patients
- Supporting pharmacy professionals following a medication incident
2. Just Culture Website
Health Quality Council of Alberta (free)
The Health Quality Council of Alberta’s Just Culture website is full of information for healthcare professionals looking for resources about just culture. The Just Culture website is easy to navigate with user-friendly layout and design that features information and guidance about
- Just culture principles
- Overcoming barriers to just culture
- Just policies and responses to patient safety incidents
- Resources to establish and maintain a just culture
3. BC Patient Safety and Quality Council
(Free)
The BC Patient Safety and Quality Council website combines evidence-informed strategies to shift culture, improve clinical practice, and accelerate improvement efforts. This website offers practical resources your team can use to
- Measure and improve safety culture
- Build reliable systems for teamwork and communication
- Creating culturally safe care environments
4. Institute for Healthcare Improvement
(Free – login required for most resources)
The Institute for Healthcare Improvement (IHI) uses improvement science to advance and sustain better outcomes in health and health care across the world. IHI works collaboratively to spark innovative ways to improve the health of individuals and populations. The IHI website is a rich source of safety and just culture resources including
- Effective leadership
- Teamwork and communication
- Task design and management
- Improving patient experience
- Developing a just and safe culture
