Blaming, naming and a just culture

Abstract

Background Problematic cultures within NHS trusts are repeatedly cited as contributing to failures in patient safety and care. The NHS has attempted to address this through promotion of a Just Culture having recognised the improvements made by other safety critical sectors, including aviation, following its adoption. Changing the culture of an organisation is a significant leadership challenge that goes far beyond the revision of management processes. Story of self I served as a Helicopter Warfare Officer in the Royal Navy prior to commencing medical training. In this article, I reflect on a near miss incident that I was involved in during my previous career and examine the attitudes of myself and my colleagues, and the practices and behaviours of the squadron's leaders. Conclusion This article compares my experience within aviation to that of my medical training. Lessons are identified that are relevant to medical training, professional expectations, and the management of clinical incidents to support the implementation of a Just Culture within the NHS.

Keywords: health policy; improvement; medical leadership; patient safety; values.