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Just Culture and the Tragedy of the Twin Casualties of Medical Error

NBC News recently highlighted the suicide of a longtime critical care nurse at Seattle Children’s Hospital. She committed suicide seven months after she accidentally overdosed an 8-month-old with calcium chloride. [1]  Her medical error, caused the death of the child, her employment termination, and a state investigation. These events and her suicide highlight the “second victim” phenomenon of medical mistakes.  In this case, state attorneys said that the child’s fragile condition and poor prognosis would have made it difficult to prove that the overdose caused the child’s death five days later.  However, the damage was done and the second victim took her own life.

The term “second victim” was coined by Dr. Albert Wu. [2]  Dr. Wu is a Professor of Health Policy and Management at the Johns Hopkins School of Public Health.  Id.  He is a leading expert on the psychological impact of medical errors on patients and medical providers.  Id.

The second victim of medical mistakes is the medical provider who made the error leading to the serious injury of their patient.  When the medical provider who made the error is the subject of a lawsuit, that provider is targeted by the plaintiff’s attorney as being largely responsible for the plaintiff’s condition. The medical provider may also be subjected to scrutiny during quality assurance meetings and even a state investigation.  Our punitive culture fails to fully comprehend the psychological impact all these events have, upon the medical provider.

That is part of the reason why some hospitals are implementing the “Just Culture” model, which recognizes the psychological impact of medical error investigations. This model and focuses on identifying and correcting systemic problems, rather than focusing on penalizing individuals.  The theory regarding the punitive culture is that medical providers are less likely to report errors, if they know that the error will likely result in punishment.  Patient safety is jeopardized when medical errors go unreported.  Therefore, the Just Culture system provides a twofold benefit in improving patient safety and improving medical provider practice.

Recognizing that no system will ever be perfect, a Just Culture system balances a blame-free culture and a punitive culture, to design a system to improve the factors impacting patient care.  These factors include:  a system to reduce the rate of human errors; barriers to prevent failure; recovering from system failures before they become critical; and limiting the effects of failure. These factors are all implemented to improve the patient care and safety at the institution.  Critical to a Just Culture program is the focus upon the system failure instead of the individual failure to permit the provider to grow within the culture rather than focusing on blame for their mistakes.

The American Nurses Association issued a position statement endorsing the Just Culture concept, on January 28, 2010. [3] The ANA recognized that the Just Culture Concept establishes an organization-wide mindset which positively impacts the work environment and work outcomes.  The ANA recognizes that medical errors that are not deliberate or malicious should result in coaching, counseling, and education. This will reduce the likelihood of a repeated error.

Seattle Children’s Hospital implemented a Just Culture system after the termination of the nurse who made the fatal calcium chloride error leading to the death of an 8 month-old.  There is no evidence that such a system would have saved the nurse’s life, but a Just Culture or a similar system may have rehabilitated the nurse, rather than allowing her to shoulder the blame of the death.

If you are the subject of a medical malpractice case or a state investigation of a medical error involving your practice, hire an attorney.  The attorneys at Chapman Law Group have expertise in navigating medical malpractice and state investigation of medical errors.  You should not delay in protecting your rights.


[1] http://www.nbcnews.com/id/43529641/ns/health-health_care/t/nurses-suicide-highlights-twin-tragedies-medical-errors/#.Va-jaflVhBc
[2] http://webmm.ahrq.gov/perspective.aspx?perspectiveID=101
[3] http://nursingworld.org/psjustculture