How effectively has a Just Culture been adopted? A qualitative study to analyse the attitudes and behaviours of clinicians and managers to clinical incident management within an NHS Hospital Trust (27 January 2023)

Summary

This article in BMJ Open Quality aimed to improve patient safety by examining the organisational and individual factors that contribute to adverse events, enabling corrective action so that errors are not repeated. Using interviews and observations of Trust meetings at a single Hospital Trust in the Midlands, England, this qualitative study:

• analysed whether the attitudes and behaviours of clinicians and managers are aligned with a Just Culture.
• identified barriers and enablers to an organisation adopting a Just Culture.

The study found evidence of a fair incident management process within the Trust; however, there was no agreed vision of a Just Culture and the majority of the staff were unfamiliar with the term. Negative perspectives relating to clinical incidents and their management persist among staff with many having concerns about being the subject of an investigation and doubts about whether they drive improvement.

Content

Recommendations from the study

1. Just Culture: define an agreed vision of what Just Culture means to the Trust.
2. Investigations: introduce incident management familiarisation training.
3. Learning Culture: increase face-to-face communication of outcomes of investigations and incident review.
4. Investigators: establish an incident investigation team to improve the timeliness and consistency of investigations and the communication and implementation of outcomes.