ABSTRACT
Medical error will occur in all health-care institutions, regardless of design. Because any approach to managing error benefits and burdens specific individuals and competes with other values, the choice raises issues of justice. The traditional approach—identifying medical professionals in closest proximity to errors and punishing offending behavior—is often fundamentally unjust. This punitive approach not only is unfair, but also incentivizes hiding or miscasting errors. As a result, systems cannot be improved.
A restorative just-culture approach to patient safety distributes benefits and burdens fairly among professionals. It standardizes error management, avoids both a “punitive” and “blameless” ethos, balances learning and accountability, openly scrutinizes its own weaknesses, reduces anxiety around error reporting, and better protects clinicians made vulnerable by power hierarchies in the medical workplace. This improves health outcomes, system management, and employee morale.
This chapter outlines the primary features of restorative just culture, comparing and contrasting it with more retributive approaches. It then considers two important objections raised against this approach as undermining traditional notions of individual moral and professional accountability. It concludes by defending both a systems-level focus and forward-looking view of accountability against these objections as well as on independent grounds.
