Organisational culture

“The fair treatment of staff supports a culture of fairness, openness and learning in the NHS by making staff feel confident to speak up when things go wrong, rather than fearing blame.” NHS Improvement, 2018 

A ‘just’ culture has an important role to play in the management of patient safety incidents.

Organisations with a ‘just’ culture:

  • know incidents are rarely down to one individual
  • have a fair process to decide culpability
  • learn from incidents
  • promote the well-being of their staff

Organisations with a ‘just’ culture know incidents are rarely down to one individual

One common response to patient safety incidents within the NHS is to find the people who made the errors and to punish or re-train them. Although this might seem to solve the problem, this response does not actually help to make care safer for patients. This is because adverse events are rarely the fault of an individual, but instead the fault of groups of people working within a faulty system.

A large survey of healthcare professionals in America – the Agency of Healthcare Research and Quality safety culture survey – found that over a quarter of respondents said that whenever pressure builds up, managers want staff to work faster, even if it means taking shortcuts. Half of the healthcare professionals surveyed said they work in crisis mode, trying to do too much, too quickly, and over a third reported that safety is sacrificed to get more done. This situation is all too familiar in the UK too.

This pressure to get more done in less time can lead to errors or workarounds, and some of these errors or workarounds may result in harm to a patient – an adverse event or even a death. If staff are being encouraged to work unsafely then we might ask whether it is unjust to punish them when things go wrong. Organisations with a ‘just culture’ recognise this.

"We need to recognise that when things go wrong, it’s not usually because people have made a deliberate mistake and therefore we actually need to support them … how can we make the right thing the easy thing to do?"

Organisations with a ‘just’ culture have a fair process to decide culpability

Although incidents are rarely down to one individual’s behaviour, there are still instances where staff have behaved recklessly, or deliberately deviated from protocols that the majority of others adhere to. In this case, they should, of course, be held to account for their behaviour, but such instances are rare. NHS Improvement have produced a ‘just culture guide’ to help managers decide on culpability in patient safety incidents. They advocate questions probing five key areas:

Deliberate harm – was there any intention to cause harm?

Health – are there indications of substance abuse, physical ill health or mental ill health?

Foresight – did the individual depart from a routinely used protocol?

Substitution – did the individual behave as a peer might have done?

Mitigating circumstances – were there any significant mitigating circumstances?

For further information, see the reference below.

Organisations with a ‘just’ culture learn from incidents

There is evidence that where an unjust culture operates, staff respond by choosing not to report safety incidents for fear of retribution. In contrast, organisations with a ‘just’ culture respond to incidents by understanding them and learning the lessons, and these are the organisations where staff are least likely to suffer if they make a mistake. Sadly, this response remains far too rarely seen. We conducted a survey of over one thousand UK doctors, and they told us that reporting an adverse event resulted in local improvements less than a quarter of the time, and in systems changes less than a fifth of the time.

The Patient Safety Incident Response Framework

The introductory NHS England and NHS Improvement Patient Safety Incident Response Framework describes a new approach to incident management, one which facilitates inquisitive examination of a wider range of patient safety incidents “in the spirit of reflection and learning” rather than as part of a “framework of accountability”.  Informed by feedback and drawing on good practice from healthcare and other sectors, it supports a systematic, compassionate and proficient response to patient safety incidents; anchored in the principles of openness, fair accountability, learning and continuous improvement.

Organisations with a ‘just’ culture promote the well-being of their staff

Having a ‘just’ culture is about more than response to incidents. For example, when teams receive feedback about actions taken as a result of leadership walk-rounds, this can impact positively on staff wellbeing and safety culture (Sexton et al., 2017).


Sexton, J. B., Adair, K. C., Leonard, M. W., Frankel, T. C., Proulx, J., Watson, S. R., … & Frankel, A. S. (2017). Providing feedback following Leadership WalkRounds is associated with better patient safety culture, higher employee engagement and lower burnout. BMJ Qual Saf, bmjqs-2016.

Creating a workplace where NHS staff can flourish – The King’s fund

A just culture guide – NHS Improvement

NHS England and NHS Improvement Patient Safety Incident Response Framework

"I think we need to be clearer about what we’re intending to do when we declare errors. That’s different from reporting a violation, where somebody’s deliberately done something wrong; but at the moment they’re almost treated in similar fashion."

Second victim support systems

Many organisations want to improve the support they offer their staff after they have been involved in a patient safety incident, and are looking at ways to achieve this. These two case studies give examples of support systems established in the UK.

Case study 1 – Leeds Incident Support Team (Leeds Teaching Hospitals NHS Trust) – peer support service for second victims


The risk management office at Leeds Teaching Hospitals NHS Trust (LTHT)


Support for second victims provided by staff members who have themselves been involved in an incident and have made a commitment to be available to talk to other staff in a similar situation.

LIST members are identified by badges with the LIST logo, and a central list of these staff members is held by the risk management office.  They have been trained to provide advice and support relating to the investigation process

Individuals who have been involved in an incident are able to approach any member of staff with a LIST logo for support, or contact the risk management office to be put in touch with someone.

The LIST function operates in addition to the Trust’s wider staff support offer including support from line managers, the Employee Assistance Programme (access to counselling), Clinical Psychology and the Occupational Health service.  If LIST members have concerns about a colleague’s health and well-being they have information to “signpost” the member of staff to these other services for help.

Further information:

Scott, S.D., Hirschinger, L.E., Cox, K.R., McCoig, M., Hahn-Cover, K., Epperly, K.M., Phillips, E.C. and Hall, L.W., 2010. Caring for our own: deploying a systemwide second victim rapid response team. Communication of Critical Test Results.

Case study 2 – Critical Incident Stress De-Briefing Team (Bradford District NHS Foundation Trust)


Twelve members of staff have completed training to receive accrediation as stress debriefers.


Bradford District Care NHS Foundation Trust (BDCT) is committed to providing a timely and supportive response in the aftermath of serious incidents. The World Health Organization et al (2011) developed guidance on psychological first aid and the structured debriefing of those affected by stress situations and symptoms in the workplace. Critical Incident Stress Debriefing (CISD) is a recommended approach for supporting teams to have space to process their experience of the impact of serious incidents (Harrison & Wu (2017) and particularly focusses on how people are coping and can support one another to cope with that impact.

Full case study here.

Why support second victims

There is now a huge amount of evidence from different countries and across different professional groups that being involved in a patient safety incident, particularly one where the patient is seriously harmed or dies can be very distressing (Sirriyeh, Lawton and Gardner, 2010). The feelings of guilt, shame, incompetence, anxiety that are reported to be experienced by staff in these situations are heightened when the individual feels that it was their error or mistake that caused the adverse event. Of the 1,463 doctors we surveyed in the UK (Harrison, Lawton and Stewart, 2014), 76% believed that the experience of a patient safety incident had affected them personally or professionally, 74% reported stress, 68% anxiety, 60% sleep disturbance and 63% lower professional confidence. Moreover, 81% became anxious about the potential for future errors. It is not only doctors who suffer. In fact, in another study (Harrison et al., 2015) we found that nurses showed higher levels of distress following an adverse event than doctors.

For many people the emotional impact of the error is short-lived, but for some the effects are long-lasting. In our sample, 8% of doctors reported symptoms associated with post-traumatic stress disorder. This is why the term ‘second victim’ was coined. The emotional impacts of making an error are many, but there are other impacts too that make it so important that we don’t ignore, or even punish further, those that have been involved in an adverse event. There is evidence that a loss of confidence and distress that is often exacerbated by the incident investigation process can lead to burnout, hyper-vigilance and the practice of defensive medicine. Without support, second victims may even choose to leave the profession. From a moral standpoint, supporting people in distress is essential. There is also a safety and financial imperative to do so.

Patient Safety Incident Response Framework

To support the NHS to further improve patient safety, NHS England and NHS Improvement are introducing a new Patient Safety Incident Response Framework (PSIRF). It outlines how providers should respond to patient safety incidents and how and when a patient safety investigation should be conducted.

The PSIRF is a key part of the 2019 NHS Patient Safety Strategy. The strategy describes how the NHS will continuously improve patient safety, building on the foundations of a safer culture and safer systems.

Step three of the PSIRF sets out how the needs of those affected by patient safety incidents – patients, families, carers and staff – are met. Organisations must establish procedures to identify all staff who may have been affected by a patient safety incident and to provide access to the support they need. Appendix three lists the national sources of support for healthcare professionals affected by a patient safety incident, including this Second Victim Support website.


Sirriyeh, R., Lawton, R., Gardner, P., & Armitage, G. (2010). Coping with medical error: a systematic review of papers to assess the effects of involvement in medical errors on healthcare professionals’ psychological well-being. Qual Saf Health Care, 19(6), e43-e43.

Harrison, R., Lawton, R., & Stewart, K. (2014). Doctors’ experiences of adverse events in secondary care: the professional and personal impact. Clinical Medicine, 14(6), 585-590.

Harrison, R., Lawton, R., Perlo, J., Gardner, P., Armitage, G., & Shapiro, J. (2015). Emotion and coping in the aftermath of medical error: a cross-country exploration. Journal of patient safety, 11(1), 28-35.

NHS England NHS Improvement (2019) The NHS Patient Safety Strategy. Safer culture, safer systems, safer patients.

NHS England NHS Improvement (2020) Patient Safety Incident Response Framework. An introductory framework for implementation by nationally appointed early adopters.