College Connection | Fall 2025
Risk-based decision-making promotes learning from errors.
College Connection | Fall 2025
JUST CULTURE
Risk-based decision-making promotes learning from errors.
During the course of a veterinary professional’ s career, errors do occur. Errors are not necessarily reflective of poor training, skills or knowledge. Typically, they are inadvertent. Just culture is one way the College ensures these errors are managed with fairness and compassion. This approach focuses on improving quality care and safe outcomes for patients.
What does just culture mean?
A just culture accepts that humans are imperfect and that conditions in complex environments will inevitably cause occasional human error. Just culture considers the role of the system in giving rise to errors and seeks to learn from incidents and errors. It proposes that disciplinary action should be tied to an individual’ s behavioural choices, rather than on the outcome of their actions. A just culture approach considers an individual’ s intent with respect to an undesirable outcome.
In other words, a just culture approach is the recognition of upholding safety in complex systems and environments where the risks are high. There is an emphasis on reporting safety incidents( errors or near misses) to learn about how errors happen and potential system failings, and holding people accountable for their behavioural choices when appropriate.
Use of a just culture approach
When there is an undesirable outcome, such as a patient safety incident, human error may not be solely to blame for the harm. It should not be the only place we look to find the root cause for the outcome.
The appropriate regulatory response uses the just culture approach, which moves away from a blame culture and a punitive system. Approaches that focus on punishing individuals as a deterrence mechanism, discourage people from reporting errors. A punitive approach doesn’ t help individuals learn from their mistakes.
Learning and education are the initial approach to addressing errors and lowrisk behaviours.
Risk-based regulatory decision-making
Just culture forms the foundation for how the College committees review concerns.
Disciplinary action is used to deter intentionally or knowingly unsafe actions. It is considered for high-risk situations where there has been bad intent, reckless behaviour, incompetence, ungovernable behaviour, or a failure to remediate previously identified at-risk behaviours.
If an individual exhibits negligent or at-risk behaviour and should have known but were unaware of the risks that they were taking, or may have believed the risks to be justified, an appropriate regulatory response may involve coaching or remediation.
A just culture approach does not apply disciplinary action to individuals for unintentional human errors or for system failings over which they do not have control.
The College’ s mandate is to protect and serve the public interest through the regulation of the practice of veterinary medicine. The College Council adopted the just culture approach as a strategy for ensuring that risks are managed in a fair and compassionate manner.
In the Fall 2024 edition of College Connection, the case presented for learning in practice was one where a Complaints Committee panel decided to take no action in a case involving human error. It demonstrates how the panel used the just culture approach in their decision-making.
Like the College, you can use the just culture approach in your own practice. Acknowledge that mistakes happen, learn from them, and take steps to reduce the risk of errors reoccurring. If you work with a team, use a teambased approach that recognizes the complexity of veterinary practice, supports learning, and creates systems that prevent human error.
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