Practicing Medicine Patient Safety For PSO Members Just Culture in
Osteopathic Practice

Just Culture in
Osteopathic Practice

Transparency in practice

Just Culture in Osteopathic Practice

Fostering a fair & accountable environment in osteopathic practice

In osteopathic medicine, patient care goes beyond clinical treatment to include the emotional and psychological well-being of both patients and practitioners. A “Just Culture” creates an environment where health care professionals feel safe to report mistakes, learn from them and continuously improve. It’s about balancing accountability with learning, ensuring that errors are addressed not with blame, but with system-wide improvements.

What is a Just Culture?

A Just Culture is a culture of trust, learning and accountability. It ensures that when safety issues are reported, the response is fair and focused on understanding what went wrong, not who to blame.

Key elements

  • Trust: Health care providers are confident that reporting safety issues will lead to system improvements, not punishment.
  • Learning: Errors are used as opportunities to improve both processes and behavior, rather than focusing solely on individual fault.
  • Accountability: Holding individuals accountable for reckless actions while recognizing that most errors are due to systemic issues, not negligence.

Elements of a Just Culture for DOs

Recognizing that human errors will happen

  • Example: A DO accidentally prescribes the wrong medication. Instead of focusing on the mistake, the Just Culture approach examines why the error occurred. Was it due to unclear electronic health record (EHR) prompts, confusing protocols or time pressure?

System thinking to explore what went wrong

  • Example: A near-miss during patient treatment is reported. Instead of blaming the DO, the team investigates whether the process of double-checking patient charts was skipped due to time constraints or unclear policies.

Using errors as opportunities for organizational learning

  • Example: A patient’s records were incorrectly filed. The practice uses this as an opportunity to improve the filing system and create clearer, more intuitive procedures to prevent future mistakes.

Designing safer systems

  • Example: After an incident where a patient experienced a delay in treatment, the team redesigns the workflow to ensure better communication between departments, reducing the chance of future delays.

The role of a leader in a Just Culture

Leaders in osteopathic practices play a crucial role in fostering a Just Culture by:

  1. Collecting factual information: When an event occurs, leaders gather detailed information about what happened, focusing on system failures rather than individual blame.
    • Example: After a patient experiences a fall, the leader investigates whether proper safety measures were in place and whether the incident could have been prevented through system improvements.
  2. Promoting healing and learning: Leaders are responsible for ensuring that those involved in incidents—whether patients, practitioners or other staff—are supported.
    • Example: A DO who made an error is reassured that the focus is on preventing future errors through system improvements, not personal blame.
  3. Creating an environment of accountability without fear: Leaders must ensure that everyone feels safe to report issues while holding individuals accountable for reckless behavior.
    • Example: If a practitioner repeatedly ignores safety protocols, this is addressed with appropriate disciplinary actions, while other types of errors are used as learning opportunities.

Types of risks in osteopathic practices

In a Just Culture, it’s important to recognize the different types of risks that can lead to errors:

  1. Structural risks
    • Example: Lack of proper equipment or unclear roles can lead to mistakes.
  2. Cultural risks
    • Example: Poor teamwork or unsafe habits can result in dangerous situations for both staff and patients.
  3. Process risks
    • Example: Ineffective handoff processes or lack of double-checking critical information increases the chance of errors.
  4. Policy risks
    • Example: Ambiguous policies or missing job aids may cause confusion among staff, leading to errors.

DOs should work together with leadership to identify these risks and implement changes that improve safety and workflow.

Addressing different types of behaviors

A Just Culture acknowledges that not all mistakes are the same. There are three categories of behavior:

  1. Honest mistakes: Unintentional slips or lapses that could happen to anyone.
    • Example: Forgetting to update a patient’s chart.
    • Leader’s action: Console the individual, provide support and focus on improving systems to prevent similar errors in the future.
  2. At-risk behavior: Actions where the individual doesn’t recognize the risks or believes the risks are justified.
    • Example: Rushing through a patient assessment due to time constraints.
    • Leader’s action: Coach the individual to help them understand the risks of their actions and how to mitigate them in the future.
  3. Reckless behavior: Conscious disregard of protocols or safety standards.
    • Example: Repeatedly ignoring safety protocols.
    • Leader’s action: Counsel or discipline the individual as needed.

A leader’s role in healing & learning

When errors occur, multiple people can be affected:

  • First victim (patient): The person who was directly impacted by the error.
  • Second victim (practitioner): The individual who made the mistake may feel guilt, stress or anxiety.
  • Colleagues and team members: Others may be affected by witnessing the event or dealing with its aftermath.
  • Community: In some cases, the larger community is also impacted.

Leader’s action: Address these needs systematically, working with the team to heal, learn and ensure that everyone involved has the support they need.

Implementing a Just Culture in osteopathic practices

Encouraging open communication and reporting

DOs should feel safe to report incidents without fear of reprisal.

  • Example: A DO reports that a treatment plan was delayed due to confusion over patient records. The practice uses this information to improve the EHR system, ensuring clearer and faster access to patient information.

Coaching for improvement

Leaders and peers should coach one another to promote safe behaviors and practices.

  • Example: A senior DO mentors a junior practitioner on ensuring patient charts are updated in real time to avoid delays in care.

Systemic improvements

The focus should always be on improving systems rather than assigning individual blame.

  • Example: After a medication error, the practice improves its medication verification process rather than blaming the practitioner.

Tools for implementing a Just Culture

Incident reporting template

Use this form to report any safety issues or errors in a non-punitive manner.

Behavior differentiation tool

This tool helps distinguish between human error, at-risk behavior and reckless behavior, ensuring appropriate actions are taken.

Just Culture coaching guide

Provides leaders with guidance on how to support practitioners through coaching, focusing on learning and improvement.
Back To Top