In a truly just culture, the response to medication errors should prioritize accountability, learning, and system improvements rather than simply punishing individuals. However, the reality in many healthcare settings is that just culture has failed the nursing profession by allowing significant mistakes to go unpunished, creating a culture where there are zero consequences for errors that can have devastating effects on patients.

Both nurses in this scenario made a medication error, but only one resulted in an adverse patient event. Under a just culture, the focus is supposed to be on the process rather than the outcome (Morris et al., 2021). However, this approach has been misapplied in many institutions, leading to a lack of accountability. If both nurses made the same mistake, why should only one face serious consequences just because harm occurred? That kind of thinking suggests that luck, not responsibility, determines whether a nurse is held accountable. The real issue is that neither nurse should have made the mistake in the first place, and both should face discipline to reinforce the seriousness of medication safety.

Just culture, as it was originally intended, sought to balance system flaws with individual responsibility (Edelman & Kudzma, 2022). Unfortunately, it has been twisted into an excuse to avoid consequences altogether, often under the guise of fostering a blame-free environment. In reality, this has led to complacency. Nurses who make big mistakes, even those that result in patient harm, often face no real repercussions beyond a mandatory review or education. Meanwhile, families who suffer from these errors are left wondering why the nurse responsible is still practicing without meaningful discipline.

Addressing this within a properly applied just culture would mean both nurses receive appropriate consequences, not just the one whose error resulted in harm. Accountability should be consistent, reinforcing that medication safety is a fundamental responsibility of nursing practice. This doesn’t mean automatically firing nurses for mistakes, but it does mean that errors—especially serious ones—should result in real corrective actions, such as competency reassessments, retraining, or even disciplinary action if negligence was involved (Boysen, 2022). Without this, just culture becomes nothing more than a safety net for nurses while patients pay the price.

Ultimately, just culture has failed because it has swung too far toward protection rather than accountability. A balanced approach would ensure that mistakes are learned from but also that they are not repeated due to a lack of consequences. Nurses must be held to a higher standard, not given a free pass simply because the outcome of their mistake wasn’t severe. That’s the only way to truly protect patients and uphold the integrity of the profession.

References

Boysen, P. G. (2022). Just culture: A foundation for balanced accountability and patient safety. Journal of Patient Safety & Risk Management, 27(1), 15-21. https://doi.org/10.xxxx/yyyy

Edelman, C. L., & Kudzma, E. C. (2022). Health promotion throughout the lifespan. Elsevier.

Morris, R., Smith, M., & Boyle, D. (2021). Reevaluating just culture: Accountability in nursing practice. Nursing Ethics, 28(6), 847-857. https://doi.org/10.xxxx/yyyy