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)

February 2, 2022

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

April 6, 2022

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

January 26, 2022

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

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

February 16, 2022

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

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

August 3, 2022

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

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

March 3, 2021

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

April 14, 2021

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

June 22, 2022

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

February 9, 2022

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

May 11, 2022

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

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

October 19, 2022

Improving diagnostic performance through feedback: the Diagnosis Learning Cycle.

September 1, 2021

Speaking up about patient safety concerns: the influence of safety management approaches and climate on nurses' willingness to speak up.

July 18, 2018

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

March 23, 2022

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

April 27, 2022

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

August 4, 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

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

May 10, 2017

July 20, 2022

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

July 29, 2020

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

July 8, 2020

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

March 30, 2022

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

March 10, 2021

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

August 25, 2021

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

August 24, 2022

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

August 26, 2020

Changes in weekend and weekday care quality of emergency medical admissions to 20 hospitals in England during implementation of the 7-day services national health policy.

November 25, 2020

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

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

August 3, 2022

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

June 29, 2022

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

November 3, 2021

The problem with making Safety-II work in healthcare.

April 13, 2022

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

June 15, 2022

Peers without fears? Barriers to effective communication among primary care physicians and oncologists about diagnostic delays in cancer.

November 1, 2017

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

May 5, 2021

Reporting incidents involving the use of advanced medical technologies by nurses in home care: a cross-sectional survey and an analysis of registration data.

July 15, 2020

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

May 19, 2021

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

December 9, 2020

Application of electronic trigger tools to identify targets for improving diagnostic safety.

October 17, 2018

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

June 30, 2021

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

October 27, 2021

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

April 28, 2021

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

June 8, 2022

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

December 22, 2021

Surgeons and systems working together to drive safety and quality.

March 29, 2023

Out of sight, out of mind: a prospective observational study to estimate the duration of the Hawthorne effect on hand hygiene events.

November 11, 2020

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

March 17, 2021

August 19, 2020

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

Association of open communication and the emotional and behavioural impact of medical error on patients and families: state-wide cross-sectional survey.

February 12, 2020

Emotional safety is patient safety.

February 15, 2023

Work–life balance behaviours cluster in work settings and relate to burnout and safety culture: a cross-sectional survey analysis.

October 24, 2018

Safety cases for digital health innovations: can they work?

July 14, 2021

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

May 12, 2021

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

May 26, 2021

Applying thematic synthesis to interpretation and commentary in epidemiological studies: identifying what contributes to successful interventions to promote hand hygiene in patient care.

September 9, 2020

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

March 24, 2021

Care coordination strategies and barriers during medication safety incidents: a qualitative, cognitive task analysis.

March 10, 2021

Patient safety and the question of dignitary harms.

March 15, 2023

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

April 7, 2021

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

December 2, 2020

A mixed methods study examining teamwork shared mental models of interprofessional teams during hospital discharge.

January 8, 2020

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

December 7, 2022

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

January 9, 2019

Indication documentation and indication-based prescribing within electronic prescribing systems: a systematic review and narrative synthesis.

April 5, 2023

When doctors share visit notes with patients: a study of patient and doctor perceptions of documentation errors, safety opportunities and the patient–doctor relationship.

June 15, 2016

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

January 16, 2019

Experience of hospital-initiated medication changes in older people with multimorbidity: a multicentre mixed-methods study embedded in the OPtimising thERapy to prevent Avoidable hospital admissions in Multimorbid older people (OPERAM) trial.

December 7, 2022

Implementation of the I-PASS handoff program in diverse clinical environments: a multicenter prospective effectiveness implementation study.

November 16, 2022

Inpatient patient safety events in vulnerable populations: a retrospective cohort study.

November 18, 2020

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

Indicators for implementation outcome monitoring of reporting and learning systems in hospitals: an underestimated need for patient safety.

May 4, 2022

Moving on after critical incidents in health care: a qualitative study of the perspectives and experiences of second victims

May 11, 2022

Time series evaluation of improvement interventions to reduce alarm notifications in a paediatric hospital.

February 12, 2020

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

July 8, 2020

Why do we still page each other? Examining the frequency, types and senders of pages in academic medical services.

February 3, 2016

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

June 30, 2021

SEIPS 101 and seven simple SEIPS tools.

June 9, 2021

Interventions targeted at reducing diagnostic error: systematic review.

September 8, 2021

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

May 4, 2022

Preventable adverse drug events causing hospitalisation: identifying root causes and developing a surveillance and learning system at an urban community hospital, a cross-sectional observational study.

February 24, 2021

Now is the time to routinely ask patients about safety.

March 15, 2023

Application of human factors to improve usability of clinical decision support for diagnostic decision-making: a scenario-based simulation study.

January 8, 2020

Ensuring medication safety for consumers from ethnic minority backgrounds: the need to address unconscious bias within health systems.

November 17, 2021

Impact of medical education on patient safety: finding the signal through the noise.

February 8, 2023

Development and performance evaluation of the Medicines Optimisation Assessment Tool (MOAT): a prognostic model to target hospital pharmacists' input to prevent medication-related problems.

July 31, 2019

Effectiveness of a 'Do not interrupt' bundled intervention to reduce interruptions during medication administration: a cluster randomised controlled feasibility study.

March 15, 2017

A system-wide approach to explaining variation in potentially avoidable emergency admissions: national ecological study.

January 8, 2014

The quality of hospital work environments and missed nursing care is linked to heart failure readmissions: a cross-sectional study of US hospitals.

March 4, 2015

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

March 9, 2022

Concordance with urgent referral guidelines in patients presenting with any of six ‘alarm’ features of possible cancer: a retrospective cohort study using linked primary care records.

August 10, 2022

Documenting the indication for antimicrobial prescribing: a scoping review.

November 2, 2022

It’s time to consider national culture when designing team training initiatives in healthcare.

January 27, 2021

Delayed diagnosis of serious paediatric conditions in 13 regional emergency departments.

October 26, 2022

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