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The ethics of a “Just Culture”


The primary ethical obligation of a pharmacist is to avoid harm by filling each prescription correctly. For this reason, pharmacies, pharmacy organizations, and boards of pharmacy have adopted and espoused the principles of continuous quality improvement.

The primary ethical obligation of a pharmacist is to avoid harm by filling each prescription correctly. For this reason, pharmacies, pharmacy organizations, and boards of pharmacy have adopted and espoused the principles of continuous quality improvement. 

Regardless of the effort and time a pharmacy puts into developing and implementing its continuous quality improvement (CQI) program, one truth remains – there will still be mistakes and medication errors. No system will eliminate all errors. Anytime a medication error reaches a patient, there is a chance a patient will be injured by the mistake. Risk is the nature of the profession of pharmacy. It is an imperfect science and an awesome responsibility. 

When a mistake is made, the first reaction of those in authority is to blame someone.  There must be someone to punish. We look for the last person who worked on the prescription, and we heap shame on that person. It is easy to lapse into the 17th century mentality of “burn the witch.” Boards of pharmacy often find themselves placed in this position – they must find and punish the culprit.

CQI, however, teaches that the way to reduce medication errors is to improve the process and the workflow. The CQI theory is to look for the root cause of the error and change the system to eliminate that cause. If all we do is “burn the witch” and fire the pharmacist, then the next time the same sequences of events line up, we must find a new witch. Eventually there is no one left to fire, no one reports mistakes, and there is no improvement.

Most mistakes in the pharmacy are the result of simple human errors, which any pharmacist and technician can make. As long as human beings play any part in the practice of pharmacy, there will be human errors. We could no more eliminate all mistakes than we could stop being human. CQI systems are necessary because pharmacists and technicians are human beings. The root cause is that thing which failed to prevent our act of human frailty. 

For perhaps 90% of all the medication errors that pharmacists and pharmacy technicians make, the CQI theory of eliminating the “blame and shame” of being human works. We eliminate fear of reporting and with each reported error there is a search for the root cause and the system is improved. The risk of the next error is reduced.

At-risk behavior

There are a few medication errors, however, for which there needs to be blame assessed and for which punishment is appropriate. Very occasionally the root cause is not a process flaw or a workflow difficulty. Sometimes the root cause is the pharmacist or pharmacy technician’s at-risk behavior. At-risk behavior may be multi-tasking or trying to fill too many prescriptions at one time.

Still less common, there are times when the person’s behavior is not just at-risk, but reckless. The individual has shown a reckless disregard for the safety of his or her patients.  Among examples of recklessness is the person who arrives at work drunk or high. Sometimes we say this person has demonstrated that he or she just doesn’t care. 

If ethics includes justice, then it is incumbent upon managers, supervisors, and boards of pharmacy members to understand the differences in each of these types of action. When a medication error is the result of simple human error, then the system needs improvement. When the pharmacist or pharmacy technician exhibits at-risk behavior, then education is appropriate. Actual discipline, however, should be reserved for those persons who exhibit a reckless disregard for the safety of patients and the system. Punishment cannot be meted out according to the harm that results, but by the actions that caused it. It is easy to punish – it is hard to determine which person to punish and why.

For a discussion of the concept of Just Culture, I suggest you read Sidney Decker’s book, “Just Culture, Balancing Safety and Accountability” by Ashgate Publishing.  Also, visit www.ISMP.org and search for Just Culture.

This article is not intended as legal advice and should not be used as such.  When a legal question arises, the pharmacist should consult with an attorney familiar with pharmacy law in his or her state.

Ken Baker is a pharmacist and an attorney. He consults in the areas of pharmacy error reduction, communication, and risk management. Mr. Baker is an attorney, of counsel, with the Arizona law firm of Renaud Cook Drury Mesaros, PA. Contact Ken Baker at ken@kenbakerconsulting.com.

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