Improving responses to safety incidents: we need to talk about justice.

Alan Cribb; Jane K. O'Hara; Justin Waring

Commentary

Improving responses to safety incidents: we need to talk about justice.

February 23, 2022

Cribb A, O'Hara JK, Waring J. BMJ Qual Saf. 2022;31(4):327-330.

View more articles from the same authors.

Patient safety advocates recommend a shift from a blame culture to a just culture. This commentary describes three types of justice that exist in healthcare - retributive, no blame or qualified blame, and restorative. The authors invite debate around the concept of just culture and its role in the “real world”.

PubMed citation

Free full text

Related Resources From the Same Author(s)

Scaffolding our systems? Patients and families 'reaching in' as a source of healthcare resilience.

January 16, 2019

Exploring patient safety outcomes for people with learning disabilities in acute hospital settings: a scoping review.

June 30, 2021

Research to improve diagnosis: time to study the real world.

January 26, 2022

February 2, 2022

Use of e-triggers to identify diagnostic errors in the paediatric ED.

April 6, 2022

Humanizing harm: using a restorative approach to heal and learn from adverse events.

May 4, 2022

The problem with 'My Five Moments for Hand Hygiene'.

August 25, 2021

Improving patient safety through the involvement of patients: development and evaluation of novel interventions to engage patients in preventing patient safety incidents and protecting them against unintended harm.

November 16, 2016

A scoping review of real-time automated clinical deterioration alerts and evidence of impacts on hospitalised patient outcomes.

August 3, 2022

We're all in this together: how COVID-19 revealed the co-construction of mindful organising and organisational reliability.

February 9, 2022

Determining the skills needed by frontline NHS staff to deliver quality improvement: findings from six case studies.

June 8, 2022

Reporting of health information technology system-related patient safety incidents: the effects of organizational justice.

October 6, 2021

Safety cases for digital health innovations: can they work?

July 14, 2021

The future of engaging patients and families for patient safety.

October 18, 2023

How do hospital inpatients conceptualise patient safety? A qualitative interview study using constructivist grounded theory.

October 19, 2022

Unacceptable behaviours between healthcare workers: just the tip of the patient safety iceberg.

June 15, 2022

Time out! Rethinking surgical safety: more than just a checklist.

April 28, 2021

Barcode medication administration technology use in hospital practice: a mixed-methods observational study of policy deviations.

August 4, 2021

The problem with making Safety-II work in healthcare.

April 13, 2022

How safe are paediatric emergency departments? A national prospective cohort study.

August 3, 2022

Safety implications of remote assessments for suspected COVID-19: qualitative study in UK primary care.

March 23, 2022

Impact of unacceptable behaviour between healthcare workers on clinical performance and patient outcomes: a systematic review.

February 16, 2022

Patient and family involvement in serious incident investigations from the perspectives of key stakeholders: a review of the qualitative evidence.

August 17, 2022

August 19, 2020

I-PASS handover system: a decade of evidence demands action.

May 12, 2021

Looking back on the history of patient safety: an opportunity to reflect and ponder future challenges.

November 3, 2021

Examining the effect of quality improvement initiatives on decreasing racial disparities in maternal morbidity.

May 4, 2022

Moving beyond the weekend effect: how can we best target interventions to improve patient care?

June 30, 2021

User-testing guidelines to improve the safety of intravenous medicines administration: a randomised in situ simulation study.

July 29, 2020

A qualitative formative evaluation of a patient-centred patient safety intervention delivered in collaboration with hospital volunteers.

August 2, 2017

SEIPS 101 and seven simple SEIPS tools.

June 9, 2021

Effect of the surgical safety checklist on provider and patient outcomes: a systematic review.

April 27, 2022

The effectiveness of interruptive prescribing alerts in ambulatory CPOE to change prescriber behaviour and improve safety.

May 5, 2021

National improvements in resident physician-reported patient safety after limiting first-year resident physicians' extended duration work shifts: a pooled analysis of prospective cohort studies.

May 25, 2022

Emotional safety is patient safety.

February 15, 2023

Use of patient complaints to identify diagnosis-related safety concerns: a mixed-method evaluation.

March 3, 2021

Striving for high reliability in healthcare: a qualitative study of the implementation of a hospital safety programme.

June 22, 2022

Identifying Risks and Monitoring Safety: the Role of Patients and Citizens.

November 6, 2013

Patient safety and the question of dignitary harms.

March 15, 2023

Support for healthcare professionals after surgical patient safety incidents: a qualitative descriptive study in 5 teaching hospitals.

May 26, 2021

Economic evaluation of quality improvement interventions to prevent catheter-associated urinary tract infections in the hospital setting: a systematic review.

March 30, 2022

Apology laws and malpractice liability: what have we learned?

July 8, 2020

Identifying and encouraging high-quality healthcare: an analysis of the content and aims of patient letters of compliment.

August 5, 2020

Surgeons and systems working together to drive safety and quality.

March 29, 2023

Systematic review and meta-analysis of interventions for operating room to intensive care unit handoffs.

March 10, 2021

"Change is what can actually make the tough times better": a patient-centred patient safety intervention delivered in collaboration with hospital volunteers.

November 14, 2018

The problem with…using stories as a source of evidence and learning.

March 9, 2022

Tiered daily huddles: the power of teamwork in managing large healthcare organisations.

October 7, 2020

Timeout procedure in paediatric surgery: effective tool or lip service? A randomised prospective observational study.

March 24, 2021

Improving diagnostic performance through feedback: the Diagnosis Learning Cycle.

September 1, 2021

Nursing implications of an early warning system implemented to reduce adverse events: a qualitative study.

May 11, 2022

July 20, 2022

Improving peripherally inserted central catheter appropriateness and reducing device-related complications: a quasiexperimental study in 52 Michigan hospitals.

April 14, 2021

Documenting the indication for antimicrobial prescribing: a scoping review.

November 2, 2022

What do patients and their carers do to support the safety of cancer treatment and care? A scoping review.

December 14, 2022

Associations between double-checking and medication administration errors: a direct observational study of paediatric inpatients.

August 26, 2020

Effects of CPOE-based medication ordering on outcomes: an overview of systematic reviews.

July 8, 2020

Incidence, origins and avoidable harm of missed opportunities in diagnosis: longitudinal patient record review in 21 English general practices.

June 30, 2021

The role of emotion in patient safety: are we brave enough to scratch beneath the surface?

January 27, 2016

Diagnostic error experiences of patients and families with limited English-language health literacy or disadvantaged socioeconomic position in a cross-sectional US population-based survey.

February 16, 2022

Incidence, nature and causes of avoidable significant harm in primary care in England: retrospective case note review.

December 16, 2020

Filling a gap in safety metrics: development of a patient-centred framework to identify and categorise patient-reported breakdowns related to the diagnostic process in ambulatory care.

October 27, 2021

Factors influencing physician responsiveness to nurse-initiated communication: a qualitative study.

December 2, 2020

Quality improvement as a primary approach to change in healthcare: a precarious, self-limiting choice?

December 7, 2022

Associations of workflow disruptions in the operating room with surgical outcomes: a systematic review and narrative synthesis.

June 17, 2020

Incidence and characteristics of adverse events in paediatric inpatient care: a systematic review and meta-analysis.

January 25, 2023

Effect of contextual factors on the prevalence of diagnostic errors among patients managed by physicians of the same specialty: a single-centre retrospective observational study.

February 8, 2023

Helping healthcare teams to debrief effectively: associations of debriefers' actions and participants' reflections during team debriefings.

August 24, 2022

Speaking up about traditional and professionalism-related patient safety threats: a national survey of interns and residents.

May 10, 2017

The debrief imperative: building teaming competencies and team effectiveness.

November 16, 2022

Is there a role for patients and their relatives in escalating clinical deterioration in hospital? A systematic review.

December 7, 2016

Nurse staffing, nursing assistants and hospital mortality: retrospective longitudinal cohort study.

January 9, 2019

Medical crisis checklists in the emergency department: a simulation-based multi-institutional randomised controlled trial.

March 17, 2021

Publication of inspection frameworks: a qualitative study exploring the impact on quality improvement and regulation in three healthcare settings.

October 6, 2021

Managing teamwork in the face of pandemic: evidence-based tips.

June 24, 2020

Exploring how ward staff engage with the implementation of a patient safety intervention: a UK-based qualitative process evaluation.

August 2, 2017

Patient and public co-creation of healthcare safety and healthcare system resilience: the case of COVID-19.

July 5, 2023

Effects of interorganisational information technology networks on patient safety: a realist synthesis.

December 9, 2020

Surgical safety checklist audits may be misleading! Improving the implementation and adherence of the surgical safety checklist: a quality improvement project.

December 22, 2021

Impact of providing patients access to electronic health records on quality and safety of care: a systematic review and meta-analysis.

July 8, 2020

Should electronic differential diagnosis support be used early or late in the diagnostic process? A multicentre experimental study of Isabel.

October 27, 2021

Overdiagnosis and overtreatment as a quality problem: insights from healthcare improvement research.

May 9, 2018

Decreased incidence of cesarean surgical site infection rate with hospital-wide perioperative bundle.

September 29, 2021

Effects of a refined evidence-based toolkit and mentored implementation on medication reconciliation at 18 hospitals: results of the MARQUIS2 study.

May 19, 2021

Evaluating the safety of mental health-related prescribing in UK primary care: a cross-sectional study using the Clinical Practice Research Datalink (CPRD).

September 15, 2021

Does team reflexivity impact teamwork and communication in interprofessional hospital-based healthcare teams? A systematic review and narrative synthesis.

February 5, 2020

Outcome differences between surgeons performing first and subsequent coronary artery bypass grafting procedures in a day: a retrospective comparative cohort study.

June 29, 2022

RaDonda Vaught, medication safety, and the profession of pharmacy: steps to improve safety and ensure justice.

August 17, 2022

"Water cooler" learning: knowledge sharing at the clinical "backstage" and its contribution to patient safety.

September 1, 2010

Leadership through crisis: fighting the fatigue pandemic in healthcare during COVID-19.

March 31, 2021

Systemic safety inequities for people with learning disabilities: a qualitative integrative analysis of the experiences of English health and social care for people with learning disabilities, their families and carers.

March 2, 2022

Impact of structured interdisciplinary bedside rounding on patient outcomes at a large academic health centre.

July 22, 2020

Effects of tall man lettering on the visual behaviour of critical care nurses while identifying syringe drug labels: a randomised in situ simulation.

April 20, 2022

Interventions targeted at reducing diagnostic error: systematic review.

September 8, 2021

Effects of night surgery on postoperative mortality and morbidity: a multicentre cohort study.

December 23, 2020

Chronic hospital nurse understaffing meets COVID-19: an observational study.

September 9, 2020

On higher ground: ethical reasoning and its relationship with error disclosure.

April 24, 2013

Vulnerability of the medical product supply chain: the wake-up call of COVID-19.

November 25, 2020

Retrospective analysis of reported suicide deaths and attempts on Veterans Health Administration campuses and inpatient units.

September 23, 2020

Crisis checklists in emergency medicine: another step forward for cognitive aids.

April 7, 2021

Related Resources

Power of saying ‘I Don’t Know’: psychological safety and participatory strategies for healthcare leaders.

March 13, 2024

Validation and use of the Second Victim Experience and Support Tool questionnaire: a scoping review.

December 20, 2023

Challenge Competition: Impact of Patient Safety Tools.

December 12, 2023

Unequal Treatment Revisited: A Workshop Series.

September 26, 2023 - September 27, 2023

Network of Patient Safety Databases Chartbook.

November 8, 2023

Right Kind of Wrong: Why Learning to Fail can Teach us to Thrive.

October 18, 2023

Defining speaking up in the healthcare system: a systematic review.

September 20, 2023

Patient, carer and family experiences of seeking redress and reconciliation following a life-changing event: systematic review of qualitative evidence.

August 2, 2023

Issues and complexities in safety culture assessment in healthcare.

July 19, 2023

Identifying a list of healthcare 'never events' to effect system change: a systematic review and narrative synthesis.

July 12, 2023

An integrative systematic review of employee silence and voice in healthcare: what are we really measuring.

June 28, 2023

Context matters: toward a multilevel perspective on context in clinical reasoning and error.

June 21, 2023

Awareness of racial and ethnic bias and potential solutions to address bias with use of health care algorithms.

June 21, 2023

Room of horrors simulation in healthcare education: a systematic review.

June 21, 2023

Individual characteristics that promote or prevent psychological safety and error reporting in healthcare: a systematic review.

May 10, 2023

Towards a unified model of accident causation: refining and validating the systems thinking safety tenets.

May 10, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Listening, Learning, Responding to Concerns.

April 12, 2023

Quality and safety: learning from the past and (re)imagining the future.

March 29, 2023

Towards conceptualizing patients as partners in health systems: a systematic review and descriptive synthesis.

March 8, 2023

Speaking up as an extension of socio-cultural dynamics in hospital settings: a study of staff experiences of speaking up across seven hospitals.

February 22, 2023

The role of bias in clinical decision-making of people with serious mental illness and medical co-morbidities: a scoping review.

February 22, 2023

AHRQ-Funded Patient Safety Project Highlights: Improving Healthcare Safety by Engaging Patients and Families.

February 15, 2023

An evidence and consensus-based definition of second victim: a strategic topic in healthcare quality, patient safety, person-centeredness and human resource management.

February 15, 2023

The woman who cried pain: do sex-based disparities still exist in the experience and treatment of pain?

February 8, 2023

The value of learning from near misses to improve patient safety: a scoping review.

January 25, 2023

A failure in the medication delivery system-how disclosure and systems investigation improve patient safety.

January 11, 2023

Posttraumatic growth and second victim distress resulting from medical mishaps among physicians and nurses.

January 11, 2023

Structural racism and adverse maternal health outcomes: a systematic review.

December 21, 2022

A recent two-fold increase in medical adverse event deaths among US inpatients.

December 21, 2022

See More About The Topic

Researchers

Hospitals

Ambulatory Clinic or Office

Medicine

Nurse Care

Improving responses to safety incidents: we need to talk about justice.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Improving responses to safety incidents: we need to talk about justice.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site