Cases & Commentaries

Fatal Error in Neonate: Does "Just Culture" Provide an Answer?

Spotlight Case
Commentary By Sidney W.A. Dekker, PhD

Case Objectives

  • Describe the just culture approach to
    investigating errors in health care.
  • Analyze system contributions to errors
    in care.
  • Identify best sources of information for
    designing a response to an error.
  • Distinguish accountability for failure
    and learning from failure.

The Case

An infant was born prematurely at 30 weeks
weighing only 1.8 kg. In the neonatal intensive care unit, he was
started on total parenteral nutrition (TPN) with Premasol amino
acid solution at 3 g/kg/d and dextrose 12.5%, 5 mg/kg/min. After
being maintained using those solutions for the first 2 days after
delivery, the care team added lipids on day 3. This was ordered as
lipid emulsion 20% at a rate of 0.19 mL/hr.

The neonatal intensive care unit had frequent
orders for this treatment and kept a stock of lipid emulsion on
site. This practice avoided the delay between ordering, sending the
order to the pharmacy, and waiting for the pharmacy to dispense the
new TPN solution.

Within 4 hours of beginning the lipid emulsion
administration through the TPN line using a smart pump, the
infant's condition worsened. He showed signs of respiratory
distress, pulmonary hypertension, coagulopathy, and liver failure.
Soon after, the infant suffered a cardiac arrest and died.

As the symptoms displayed by
this premature infant suggested lipid overload, the dose and rate
of administration of the lipid formulation were assessed.
Assessment revealed that the pump was set to deliver 19.0 mL/hr. In
the process of calculating the dose with the concentration of lipid
emulsion available on the unit, the RN had erroneously set the pump
to deliver 100 times the ordered dose of 0.19 mL/hr. Upon discovery
of the error, the nurse involved was fired by the hospital and her
license was revoked. The sequence of events and underlying reasons
for the error were not investigated further.

The Commentary

This case is severe and shocking, as is the
outcome: the death of an infant. In the aftermath of such an event,
health care providers and organizations must search for the most
appropriate response. Here are a series of questions and answers
designed to help in choosing the best and most useful response.

Is the just culture framework helpful for how
an organization should respond?

Yes. Firing the nurse and having her license
revoked, while doing nothing to investigate the system issues
surrounding the error (e.g., technology and interface ergonomics,
lipid administration for neonates, dose calculation routines,
clinical response to signs of trouble), could be seen as deeply
unjust. Unjust not only for the nurse, but also for the family of
the deceased: what confidence can they have that this won't happen
again; that another patient will not suffer from a similar mishap
in the future? A just culture balances accountability with
What we see here is only (one very narrow form of) accountability,
and no learning. A lost opportunity, a wasted death.

How can investigators determine whether this
is an error, or at-risk or reckless behavior?

Determining whether this is an honest error or
at-risk/reckless behavior is a very difficult judgment, and the
outcome depends more on who is involved in making it than on the
behavior itself. So my advice: First, ask the nurse. Then ask other
nurses when you explain the case to them. Finally, look at how
often (and under what circumstances) this or something similar has
happened, either at your own facility or elsewhere. Whether it is
an honest error or something more sinister is not easily determined
by looking at the act and its circumstances alone—it is a
judgment call on the part of the people assessing somebody's
performance after the fact, much more than it is a ready-formed or
inherent feature of that performance. What can look reckless from
one perspective (e.g., the hospital's lawyer or administrator or
doctor) can look quite honest, normal, and understandable from
another (e.g., the nurses who work in the organization's messy
environment every day). So be sure to involve multiple viewpoints
when determining whether this is an honest error or something
worse, and fairly balance them. Don't just take anybody's word for
it. In general, your concern should be why good nurses
make mistakes, not why bad nurses do so, because very few nurses
come to work to do a bad job.

How can an investigator determine the system

Independent of what you believe about the error,
study the system and the organization that helped bring forth this
error or behavior. Do three things to determine why it made sense
for the nurse to do what he or she did. First, figure out what
multiple (and often conflicting) goals influenced the performance.
How many other patients were there at the time; how long had the
nurse been on shift? Were there time pressures, organizational or
managerial expectations, or protocol or procedures that would get
in the way of getting the job done? Second, determine the
(clinical) knowledge of the person involved: did he or she have
sufficient training for the task at hand; was there a mismatch in
the mental model about the technology, the patient, the drug, the
procedure? Third, what was the nurse focused on or looking at
during preparation and administration; was his or her attention
directed to the task or distributed across multiple tasks?

What is the recommended response in case of
an error or at-risk/reckless behavior?

First, ask the nurse. What does the person
involved believe should be done? This is one of the best starting
points for a just culture. People closest to the mishap often feel
responsible and eager to help with suggestions for improvement, and
their immediate experience can provide the best evidence base for
useful intervention that you're ever going to get. In any case, be
sure to involve peers in any judgments of what should be done. That
is the only way to sustain a just culture, one in which remaining
colleagues can feel free to report their own mistakes without fear
of undue consequences.

How do hospitals manage these kinds of errors
in general?

Not very impressively. The simultaneous belief in
individual strength and brittleness is pervasive in health care:
Safety lies in the hands through which care ultimately flows to the
patient, not in the system that surrounds those hands. When things
go well, health care culture tends to celebrate "good doctoring"
acts by competent people who succeeded despite the organization and
its complexity. When things go wrong, health care culture often
zeroes in on people at the "sharp end" who, for once, failed to hold that complex,
pressurized patchwork together—rather than inquiring about
the systemic sources behind the production of all that complexity.
The response of the hospital in this case is, sadly, all too
typical. It may have managed the organization's risk, but it is
probably seen as very unjust by all other major stakeholders: the
nurse involved, her colleagues, and even the patient's family.

This, in the end, is how a hospital can balance
accountability and learning. Accountability is not just holding
somebody responsible by meting out punishment. It is about telling
stories of what happened. And by telling such stories, by sharing
them among colleagues, similar unnecessary deaths can be prevented.
It's accountability and learning at the same time.



  • A just culture balances learning from
    failure with accountability for failure.
  • In this lipid overdose case, the
    response can easily be seen as unjust: only (one narrow form of)
    accountability, and no learning.
  • The response, however, is probably
    typical: hospitals often want to manage their own (liability) risk
    first, with concern for their just culture coming later (if at
    all). And health care culture generally overestimates the role of
    the individual actor in bringing about clinical success or failure,
    downplaying the contribution of the system.
  • Be sure to involve multiple viewpoints
    in your determination of whether a given error represents an honest
    mistake or something worse. Fairly balance these viewpoints, don't
    just take anybody's word for it.
  • Accountability doesn't have to be all
    about meting out punishment, it can be about having people tell
    their accounts, their stories, from which others in the hospital
    can learn and improve.

Sidney W.A. Dekker, PhD
Professor and Director

da Vinci Laboratory for Complexity and Systems Thinking

Department of System

Lund University,

Faculty Disclosure: Dr. Dekker has
declared that neither he, nor any immediate member of his family,
has a financial arrangement or other relationship with the
manufacturers of any commercial products discussed in this
continuing medical education activity. In addition, the commentary
does not include information regarding investigational or off-label
use of pharmaceutical products or medical devices.


1. Dekker SWA. Just Culture: Balancing Safety and
Accountability. Farnham, UK: Ashgate Publishing Co.; 2007. ISBN:

2. Gawande A. Complications: A Surgeon's Notes on
an Imperfect Science. New York: Picador; 2003. ISBN:

3. Pellegrino ED. Prevention of medical error:
Where professional and organizational ethics meet. In: Sharpe VA.
Accountability: Patient Safety and Policy Reform. Washington, DC:
Georgetown University Press; 2004:83-98. ISBN: 158901023X.