Quick Links

Use the quick links below to find the resources and information you need to implement and maintain Safety IQ in your pharmacy.

Just and Safety Culture

A just and safety culture is the shared belief and the practice of healthcare providers that prioritizes safety when providing care to patients and a system that treats people fairly when something goes wrong.

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.

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.”

For community pharmacies, a just and safety culture optimizes learning from medication incidents and near-miss events to prevent future errors and improve patient safety. Medication incidents and near-miss events are discussed openly, and learnings are shared with the pharmacy team to prevent recurrence. Medication incidents are rarely caused by a single event or the actions of a single person. Analysis of medication incidents and near-miss events often reveal a system failure or environmental factors that must be changed to prevent medication incidents.

Resources you can use to support just and safety culture include:


Characteristics of Blame-and-Shame vs. Just-and-Safety Culture
Blame-and-Shame Culture Just-and-Safety Culture
Preoccupation with individual performance and the belief that with the hard work and focus of individuals, things will naturally improve. Preoccupation with safety and people have current knowledge about the factors that determine the safety of the system.
Open communication about incidents and near misses is discouraged directly and indirectly. Individuals are made to feel incompetent if they are involved in an incident. Reporting is absent, not used effectively, or is used to focus on individual performance. Incidents and near misses reported without fear of blame and learning is shared across the team. Every team member feels confident discussing incidents and near misses and asking questions.
Punishment is trusted as an effective way to motivate carefulness. Trust that the organization will deal people fairly when something goes wrong is predominant.
Persists with potentially faulty systems and practices in place; stop-gaps such as ‘work arounds’ are used by individuals to avoid errors. System and teams adapt to changing pressures and demands.