To create lasting change and improve patient and workforce safety, we must shift from evaluating accidents and errors after they’ ve taken place, to designing systems and cultures that prevent harm from happening in the first place.”— Marcus Schabacker, PhD
Systems Thinking in Healthcare and Culture of Safety
ECRI, a global nonprofit organization improving the quality and safety of healthcare, reminds us that despite the best efforts of healthcare personnel“… healthcare systems are fraught with challenges, leading to safety incidents that could be prevented. Understanding healthcare as a complex system is essential to tackling these challenges and improving patient safety.”( ECRI, 2025)
In a recent whitepaper, ECRI( 2025) outlines the five essential components of health systems: People, physical environment, organization, tools and technologies, and tasks and processes. These components comprise a complex network in which errors happen and can be addressed as system failures through a systems-thinking approach.
As ECRI( 2025) explains,“ Errors in healthcare often arise not solely from individual mistakes but from systemic failures. For instance, consider a situation in which a patient receives the wrong medication dosage. Initially, the focus may be on the healthcare worker who administered the medication. However, a thorough systems analysis might reveal several contributing factors.” In this instance, design flaws may contribute to a lack of clarity in the medication administration system, thus leading to confusion. Staffing issues, such as a high patient-to-nurse ratio, may lead to oversights during medication rounds. Organizational policies can contribute to errors if ineffective communication protocols hinder information sharing. Finally, ECRI says recognition that errors can stem from multiple interconnected factors allows healthcare professionals to identify all causes rather than assign blame.
When applying systems-thinking to enhance patient and healthcare personnel safety, ECRI( 2025) advises institutions and clinicians to:
● Understand Your Role: Regardless of your position, recognize that you are an integral part of the healthcare system. Your actions can directly influence patient outcomes.-
● Advocate for Safety: If you notice something amiss, speak up. Advocate for changes that will enhance safety for patients and staff alike.
● Collaborate across Disciplines: Engaging with colleagues from different roles can yield insights into systemic challenges and foster innovative solutions.
● Utilize Data and Feedback: Collect and analyze data related to incidents and near misses. Use this information to guide improvements and refine processes.
● Promote a Culture of Learning: Encourage an environment in which errors are viewed as learning opportunities. Share insights and lessons learned from incidents to prevent recurrence.
As ECRI( 2025) observes,“ In healthcare, every professional plays a vital role in ensuring safety and quality of care. By embracing a systems perspective, healthcare workers can better understand the complexities of their environment and address challenges more effectively. Improving patient safety requires collective effort, communication, and a commitment to continuous learning. By recognizing the interconnectedness of the healthcare system, professionals can foster a culture of safety that benefits everyone involved— patients, families, and healthcare workers alike. By understanding and applying systems-wwthinking principles, we can create a safer, more reliable healthcare environment, ensuring that every patient receives the highest standard of care.”
Exploring the Meaning of‘ Just Culture’ Within a Safety Culture
Late last year, ECRI acquired The Just Culture Company, which specializes in transforming workforce culture in high-risk industries and assists organizations in deploying a balanced system of accountability between the organization and employee that fosters a fair, learning culture – referred to as a“ just culture” – by implementing its proprietary algorithm through advisory services, educational programs and coaching.
“ Just culture” is an essential component of ECRI’ s Total System Safety( TSS) approach to drive efficiencies, improve healthcare and reduce preventable patient harm by designing systems for impact and sustainability.
“ Alarming rates of preventable harm are inflicted on patients every day. By offering Just Culture programs throughout ECRI’ s global network, we can prevent harm before it happens,” says Marcus Schabacker, PhD, president and CEO of ECRI.“ To create lasting change and improve patient and workforce safety, we must shift from evaluating accidents and errors after they’ ve taken place, to designing systems and cultures that prevent harm from happening in the first place.”
The Just Culture Company has partnered with healthcare providers, health departments and insurers to assess and improve workforce culture, from C-Suite to frontline staff, through a holistic systems-based approach.
“ Our just culture model is founded on the principle that workforce learning, holistic system design, mentoring, and coaching are stronger interventions than the‘ shame and blame’ culture that’ s so prolific in healthcare,” says David Marx, CEO of The Just Culture Company.“ Errors must be recognized and addressed in a way that become learning opportunities for all the people in the system.”
In this post-COVID era, a just culture within a culture of safety is more important than ever before, especially if personnel’ s accountability suffered in the last few years due to the strains the pandemic placed on the healthcare sector.
“ Accountability takes a different form in the midst of a pandemic – where putting one’ s self and family in harm’ s way was the ask of healthcare providers,” Marx says.“ We had providers working in systems unprepared for a pandemic, and the everyday rules and norms had to be set aside for the moment. High reliability gave way to survival. Fortunately, we provided each other with a tremendous amount of grace during COVID. Post-COVID, we’ re on our way back to normal. Organizations are again on the road to maximizing the effectiveness of healthcare, from access and quality of care, to wellness of healthcare providers. That means designing systems fit for that purpose, and working to build great cultures within those systems.”
It’ s important for healthcare institutions to explain to healthcare personnel what constitutes a just culture, in case they are unfamiliar with the concept.
“ I think most healthcare professionals have heard the term,‘ just culture,’” Marx says.“ Some have been a part of a‘ just culture’ implementation. Now, what was their lived experience? Our data shows that healthcare is becoming less punitive toward human errors. In fact, from our research it’ s among the least punitive industries in the U. S. That’ s a good thing. And with the right implementation, those same employees find their workplace more accountable, having less tolerance for conduct detrimental to values: from safety to patient service, to health data protection.”
Marx continues,“ Just culture cuts across all values, and that’ s why the chief human resource officer( CHRO) is key to making it work. Infection prevention, data protection, medication safety – they are all beneficiaries
20 • www. healthcarehygienemagazine. com • mar-apr 2025