In high-stakes environments such as pharmacies, where dangerous or even deadly medication errors can occur, the need for a culture of safety has become increasingly apparent. At the same time, burnout and working conditions are causing many pharmacists and technicians to leave the profession at an alarming rate, contributing to a shortage of qualified pharmacy staff. Stakeholders are searching for new models to improve safety and workplace conditions as a result of these challenges.
Many experts believe that following a “just culture” approach to reporting and responding to mistakes and potential safety issues is one of the most effective methods. But what exactly does a just culture entail, and how can it help improve patient safety and working conditions?
Understanding “Just Culture”
A just culture approach is often presented as an alternative to a “blame culture.” The idea is to create a workplace culture that encourages transparency and learning from mistakes, rather than taking disciplinary action in the event of errors or near misses. This approach recognizes that errors can occur in any system and that individuals should not bear the blame for honest mistakes.
Instead, the culture should focus on analyzing where the system failed and correcting it to prevent future mistakes. In health care, just culture is used to promote patient safety by encouraging providers to report errors and potential safety issues.
Some States Begin Adopting Just Culture Concepts
Several states have taken steps to support just culture. For example, since 2003, Oregon has supported the Oregon Patient Safety Commission (OPSC), a semi-independent state agency that collects data related to medical harm and shares it with providers to help prevent future errors of a similar nature. OPSC currently performs this duty through 2 channels.
- The Patient Safety Reporting Program (PSRP), operating since 2003, aims to reduce the risk of serious adverse events occurring in Oregon’s health care system and encourage patient safety.
- Since 2013, the Early Discussion and Resolution system has helped connect patients who experience harm with their health care providers to facilitate candid discussions about what occurred, work toward reconciliation, and contribute to safeguarding others from harm. OPSC also provides online tools and best practice resources to help health care organizations create a culture of safer care.
NABP Supports a Just Culture Approach
Recognizing how a just culture approach may help to improve patient safety and support the boards of pharmacy in their shared mission of protecting public health, we have taken several steps in support of improving pharmacist workplace safety and well-being.
Task Force Reviews Safety Measures
At the 117th NABP Annual Meeting, a resolution was approved that acknowledged several important realities: the purpose of pharmacy practice is to ensure patients receive appropriate care, are protected from potentially dangerous medications, and that medication errors that cause patient harm are a well-documented problem in the US. The resolution also authorized the creation of the Task Force on Safety-Sensitive Measures to Review Medication Errors.
When it convened in October 2021, the task force issued 2 recommendations to help the boards of pharmacy in building a safety-based culture for pharmacists:
- Creating a medication safety academy.
- Establishing educational workshops and materials.
Policy Statement Addresses Support
In a policy statement issued in 2022, NABP expressed support for just culture, particularly considering the effects from the COVID-19 pandemic. The statement highlighted the steps the boards of pharmacy and pharmacy associations are taking to address these issues, such as the development of the Pharmacist’s Fundamental Responsibilities and Rights document created by the American Pharmacists Association and the National Alliance of State Pharmacy Associations.
First Medication Safety Academy Convenes
In March, we held our first Medication Safety Academy meeting. Designed for board of pharmacy executive officers at all experience levels, the 2-day event featured discussions on preventing medication errors, implementing continuous quality improvement programs, and applying a just culture approach to increase patient safety. In addition, we have offered several educational workshops and other resources aimed to help attendees improve workplace safety.
Taking Action for Just Culture
We have also continued to take action through our task forces and committee meetings. In 2022, the members of the Work Group on Workplace Safety, Well-Being, and Working Conditions issued 5 recommendations to support a healthy work environment.
One included expanding the role of pharmacy technicians so that pharmacists can be more available to provide patient care services. Another endorsed standardizing lunch breaks and shift lengths; yet another called for utilizing more automation technology.
Medication errors are a significant concern in pharmacy and health care as a whole. We will continue to take crucial steps to address this issue, and to help promote a better working environment for pharmacists and technicians at all levels.
This blog was adapted from an article that originally appeared in the May 2023 issue of Innovations.