Reporting adverse events is essential for ensuring patient safety and fostering a culture of continuous improvement in healthcare. Adverse events, defined as unintended injuries or complications arising from healthcare management, offer crucial insights into systemic weaknesses that, if addressed, can prevent future harm. However, underreporting such events remains a significant challenge, often driven by fear of punitive actions, reputational damage or legal repercussions. To address these concerns and promote a robust reporting culture, healthcare organisations must adopt a just culture by implementing standardised frameworks for evaluating errors and establishing robust reporting systems. Transparency in handling reported incidents is critical for building trust among healthcare professionals.

Understanding just culture

Just culture represents a shift from a blame-oriented approach to one that balances accountability with a focus on systemic improvement. Originating in high-risk industries such as aviation, the concept emphasises that errors result from flawed processes rather than individual negligence. In a just culture, individuals are held accountable for their actions within a fair and transparent system that prioritises learning and improvement.

Central to the philosophy of just culture is the idea of psychological safety. When healthcare professionals feel confident reporting errors will not lead to unjust punishment, they are more likely to disclose incidents. This openness enables organisations to identify trends, address root causes and implement preventive measures. Moreover, just culture recognises the distinction between human errors, at-risk behaviours, and reckless conduct, advocating for tailored responses that align with the nature of the behaviour.

Barriers to adverse event reporting

Despite its potential, the implementation of just culture faces several obstacles. A predominant challenge is the deeply ingrained blame culture within many healthcare organisations. Historical reliance on punitive measures has created an environment where professionals fear repercussions, discouraging transparency. Additionally, managerial inconsistency in addressing errors often undermines trust in the system. For instance, discrepancies in how similar incidents are handled can create perceptions of unfairness, further discouraging reporting.

Another barrier is the lack of understanding and awareness of just culture principles among healthcare staff. Without proper training and education, employees may misinterpret the approach as being lenient or as failing to hold individuals accountable. Legal and regulatory pressures also pose challenges, as concerns about litigation can deter organisations from fully embracing non-punitive reporting frameworks.

Strategies for implementing just culture

Implementing a just culture in healthcare requires a multifaceted approach that addresses organisational, managerial and individual factors. Leadership commitment is paramount; leaders must model just cultural behaviours, demonstrate accountability and prioritise safety over blame. Developing clear policies and guidelines for error classification and response is equally important as it ensures consistency and fairness in how incidents are addressed.

Education and training programmes are vital in promoting awareness and understanding of just culture principles. These programmes should emphasise the distinction between human errors, at-risk behaviours and reckless conduct, providing staff with the tools to respond appropriately. Role-playing scenarios, workshops and case studies can help reinforce these concepts and demonstrate their practical application.

The integration of non-punitive reporting systems is another critical component. Such systems should be designed to facilitate easy and confidential reporting, with mechanisms to protect the anonymity of reporters when appropriate. Feedback loops are essential for ensuring that staff are informed about the outcomes of reported incidents, which can reinforce the value of reporting and build trust in the system.

Measuring the impact of just culture

Assessing the effectiveness of just culture initiatives requires the development of standardised metrics and evaluation tools. Key performance indicators may include reporting rates, staff perceptions of psychological safety and the frequency of systemic improvements resulting from reported incidents. Periodic surveys and interviews can provide valuable insights into staff attitudes and identify areas for improvement.

Case studies from organisations that have successfully implemented just culture can also serve as benchmarks for best practices. For instance, hospitals that report significant increases in adverse event reporting rates following the adoption of just culture principles often attribute their success to strong leadership, comprehensive training, and consistent application of policies.

 Sustaining cultural change

Sustaining a just culture requires ongoing commitment and adaptability. Organisations must regularly evaluate their policies and practices to ensure alignment with just culture principles. Staff feedback should be actively sought and incorporated into decision-making processes, fostering a sense of ownership and engagement.

Continuous education and training are essential for reinforcing just culture behaviours and addressing emerging challenges. Additionally, leadership succession planning should prioritise candidates who are committed to upholding just culture principles, ensuring continuity in organisational values.

 Conclusion

Adverse event reporting is a fundamental component of patient safety, and the principles of just culture provide a robust framework for enhancing reporting rates and fostering systemic improvements. By balancing accountability with a focus on learning and improvement, just culture creates an environment where healthcare professionals feel empowered to report incidents without fear of retribution. Leadership commitment, staff education and integrating non-punitive reporting systems are critical for overcoming barriers and sustaining cultural change.

A just culture represents a paradigm shift in addressing adverse events, emphasising systemic improvement over individual blame. Its successful adoption has the potential to transform healthcare organisations, making them safer and more resilient.

Future research should focus on developing standardized metrics to evaluate just culture initiatives and exploring their applicability across diverse healthcare settings.

Some key findings from the report include:

• Demand for a recognised, national training programme. 52% of perioperative practitioners have not received any education on the hazards of exposure to surgical smoke plume. However, 96% would attend training if it were made available.
• National guidance is needed to mandate the use of evacuation equipment during surgical procedures where surgical smoke plume is generated. 77% of perioperative practitioners do not have evacuation devices available in all operating theatres and procedure rooms at their workplaces. Only 14% said plume evacuation equipment is always used during laparoscopy / endoscopy procedures, where surgical smoke plume is readily generated and can be a hazard to patients as well as staff.
• Consistent, accurate reporting mechanisms are required to allow staff to report negative health symptoms. 72% of perioperative practitioners have experienced symptoms associated with exposure to surgical smoke plume. Only 12% reported these symptoms and, in 77% of cases, no follow-up action was taken.

1. To ensure support for doctors unwell with a long-term covid-related absence:

(i) To advocate for all doctors with Long Covid to remain in employment and to have protected income

(ii) To lobby for a contingency plan to provide support for any doctors who are unable to remain in employment due to Long Covid, including financial support

2. To actively lobby for Long Covid in the medical and healthcare workforce to be recognised as an occupational injury;

3. To actively lobby for doctors with Long Covid, as a result of occupational injury, to receive compensation.

For Government

1. Giving workers with mental health problems early access to occupationally focused healthcare, which should include helping them to obtain, remain in, or return to, appropriate work.
2. Expanding vocational support services in both NHS and community settings for patients with mental health problems to help them remain in, or return to, work.
3. Improving access to flexible benefits and sick leave for patients with chronic fluctuating health conditions to help patients remain in, or return to, work.
4. Ensuring that all employers (including the NHS) recognise the benefits of ensuring that all supervisors, from the most junior upwards, feel confident to identify potential mental health difficulties in their staff and to speak with them about such difficulties using a salutogenic approach (an approach to wellness that focuses on health rather than disease).

For the NHS:

1. All healthcare staff understand the close links between someone’s state of mental health and their ability to work. This is especially important when providing care for people who work in safety critical occupations (e.g. vehicle operators, emergency services etc).
2. All healthcare staff provide care in a way that helps patients stay in, or return to, appropriate work.
3. All NHS staff understand the key role that occupational health services have in helping to support patients staying in, or returning to, appropriate work.
4. Ensuring, as a priority, that all NHS supervisors, from the most junior upwards, feel confident enough to identify potential mental health difficulties in their staff and to speak with them about such difficulties using a salutogenic approach (an approach to wellness that focuses on health rather than disease).

For psychiatrists

1. Routinely exploring a patient’s employment history – including their current employment status – to understand what role it may have played in contributing to their state of mental health.
2. Viewing it as an important treatment outcome to help patients to obtain, remain in, or return to, appropriate work.
3. Encouraging healthcare colleagues to recognise the mental health benefits of being in work and to consider work as a key treatment outcome for any care provided.
4. Advocating for their patients by appropriately communicating with employers and occupational health providers to challenge any discrimination or stigma that exists about mental health, with the aim of helping their patients remain in, or return to, appropriate work.

For employers:

1. Ensuring that those in supervisory positions, from the most junior upwards, feel confident enough to identify potential mental health difficulties in their staff and to speak with them about such difficulties using a salutogenic approach (an approach to wellness that focuses on health rather than disease).
2. Adopting policies and practices which support people who develop mental health conditions to remain in, or return to, appropriate full- or part-time work.
3. Recognising the value of occupationally focused mental healthcare in helping their staff remain in, or return to, appropriate work.  

• who might be harmed and how
• what you're already doing to control the risks
• what further action you need to take to control the risks
• who needs to carry out the action
• when the action is needed by.

As occupational therapists our aim is to maximise independence and support people to carry out daily life activities - their ‘occupations’. These activities include self-care, leisure and productivity - ranging from brushing your teeth to going to the supermarket. Our role requires a deep understanding of the significant impact that these seemingly ordinary routines have on peoples’ health and wellbeing.

Occupational therapists are found in a variety of services across both physical and mental health. The role of an OT in any setting involves striking a balance between optimising patient safety, and positive-risk taking. Both of us are currently hospital-based and our primary role is to assess how each patient will manage at home. Our goals are to ensure patients are discharged safely and effectively and to prevent readmission. 

When working with a patient to increase their independence, we look at three areas: the person, the environment and the activity. We might make adjustments in any or all of these areas.

The person

For every patient, we consider the physical, cognitive, spiritual and psychological aspects that might affect their recovery and independence. By establishing what restricts, motivates and matters to a patient, we can tailor our support to best support them.

Fear of falling is a major barrier to independence for many patients we see in hospital, and helping them overcome the associated anxiety and lack of confidence can make a huge difference to their quality of life and ability to function. Fear of falling can result in patients displaying physical symptoms such as shaking or stiffness and avoidance behaviour. Patients can enter a deconditioning spiral of loss of confidence and anxiety, causing a reduction in activity which leads to decreased muscle strength and mobility. This in turn further decreases independence and increases the patient’s falls risk. 

As occupational therapists, we can make patients safer by helping them overcome this fear and regain mobility. There is evidence that encouraging someone to keep active through positive risk taking can increase confidence and help them form a realistic view of their falls risk. We educate patients on the actual risks and provide opportunities to learn-through-doing, helping them translate this knowledge into experience and change their behaviours. This might be as simple as suggesting a patient gets up at each advert break when watching TV, walks five steps then sits back down.

The environment

Occupational therapists consider all aspects of a patient’s environment and use clinical reasoning to decide on interventions to promote their safety and independence.

When a patient has fear of falling, we can put in place changes to the environment to help mitigate that fear as well as the actual risk of falling. 

When we look at a patient’s environment, it’s important we have a clear picture of the setting a patient will be living in. I (Susanna) hate only having a downstairs toilet because it is so far away during the night! If one of our patients was in this situation and needed easy access to a toilet, we would consider all aspects of their living space before deciding on interventions, for example:

• Do they have a partner living with them who could help if needed?
• Do they have blood pressure issues and associated risks?
• Do they have urinary urgency?
• Are they at risk of falls?

In this case, a simple urinal bottle or commode placed next to the bed can save a patient from having to travel large distances to access a toilet during the night. We could also introduce adaptations such as grab rails to assist independent toilet transfers (sitting down and standing up). As a last option at home, carers could be provided to assist with personal care in the morning.

The activity (occupation)

There is huge pressure on bed-capacity in the NHS, and occupational therapists can play a key role in patient safety in this area. We help free up beds for other patients that need them and make sure our patients are safe to be discharged. An inpatient who is medically fit for discharge is also at risk of picking up hospital-acquired infections, so we need to reduce this risk with prompt discharge. 

We carry out functional assessments of a patient’s ability to fulfil the basic activities required for independence at home: mobility, transfers from bed/chair/toilet, washing and dressing, and meal preparations. If we can find out the dimensions of a patient’s home furniture, we can sometimes replicate this on the ward to help us assess them more accurately.

Working closely with physiotherapists, we provide walking aids and assistive equipment that will make patients safer at home. We also liaise with social workers to put packages of care in place to support independence once a patient has left hospital. 

Under a new ‘discharge to assess’ government policy, this assessment process is changing to become more community-based and occupational therapists will be carrying out more of these assessments in patients’ homes. Although this is hard to picture now, it means we will get a much more accurate understanding of a patient’s occupations within their own home, where they know where things are and ‘have a knack’ of doing things their own way.

Are you an occupational therapist with an interest in patient safety, or a patient who has benefitted from working with an occupational therapist? Tell us about your interests and experiences in the comments.

Further reading

Roots of recovery: Occupational therapy at the heart of health equity (1 November 2021)

As an agency scrub nurse, I was booked to work out of London in a private clinic. This was to work two nights and two days in theatres. It was my very first agency shift.

On the way to the theatres, escorted by a porter, I slipped on the stairs whilst holding on to the rails and fell, sustaining a right dislocated shoulder. I had it relocated in A&E in a local NHS hospital and was given entonox and morphine.

I returned to London the next morning – the taxi fare of £220 was not covered by the clinic.

I have now been unemployed for many weeks due to the injury. The Agency left it to me to handle the compensation with the hospital and the Union could not help as I did not have a photo of the stairs or other evidence of steps being wet, etc. Therefore, I will get zero compensation.

Health and Safety at the hospital said I tripped over my own feet and I should have held on to the rails. When I told them that I had actually gripped the rails as it is my habit to do this anyway – they said I "should have gripped the rails tighter"! My argument is if everyone using the stairs is required to grip tightly to the rails, where are the signs to tell them to do this?

The hospital said a Riddor (Reporting of Injuries, Diseases and Dangerous Occurrences Regulations) was unnecessary. The Health and Safety Executive (HSE) accepted my Riddor report online and promised to tell the hospital of their responsibility to report my injury. 

So I urge my Agency colleagues, to be careful. If you are badly injured, ensure you or someone on your behalf takes photos so your Union can help you. Also ask your Agency about injury compensation before you accept shifts.

If you are on a permanent contract in the NHS or a private clinic and just doing the odd agency shift, you can get quick treatment and sick leave pay for your injury. However, if like me, you are on bank shifts, you get no sick leave and NHS treatment for your injury is painfully slow. I suggest investing in health insurance – I will be doing that now.

Above all, please be safe wherever you work, and extra vigilant when using steep stairs and also stairs with edges that are not non-slip covered. And most importantly, always remember to "HOLD TIGHTLY TO THE RAILS"!