The Journal of Continuing Education in Nursing

Teaching Tips 

QSEN Safety Competency: The Key Ingredient Is Just Culture

Gail Armstrong, PhD, DNP, ACNS-BC, RN, CNE


Patient safety is a familiar and long-standing competency for nurses. Effective error gap analysis is necessary to improving patient safety. Recent updates in patient safety emphasize just culture as vital to improving patient safety. This article explores how just culture has expanded the understanding of patient safety and offers some take-away tips for nurses. [J Contin Educ Nurs. 2019;50(10):444–447.]


Patient safety is a familiar and long-standing competency for nurses. Effective error gap analysis is necessary to improving patient safety. Recent updates in patient safety emphasize just culture as vital to improving patient safety. This article explores how just culture has expanded the understanding of patient safety and offers some take-away tips for nurses. [J Contin Educ Nurs. 2019;50(10):444–447.]

Patient safety has been a longstanding nursing priority in health care. Recent statistics indicate that approximately 10% of hospital admissions experience harm, with 70% of errors being preventable (Balas, Scott, & Rogers, 2004; Landrigan, 2010; Rafter et al., 2015). Keeping patients safe is deeply ingrained in nursing education and is explicitly emphasized as a foundational professional value. More recently, new knowledge has shifted the emphasis of this competency. Traditionally, patient safety was translated as an individual nurse responsibility. New awareness has emerged about the vital importance of the health care system in helping nurses to keep patients safe (Institute of Medicine, 2000).

The enduring, time-honored tradition of patient safety focused on the responsibility of nurses keeping their patients safe, often with the end goal of an individual nurse mastering the discrete skills necessary for care processes and procedures (e.g., maintaining asepsis and medication administration) (Harmer & Henderson, 1955). Modern nursing models incorporate these skills as vital elements within nursing practice, but they also emphasize that nursing is a more complex, multifaceted phenomenon. Focusing on the individual nurse or provider for patient safety suggests blame and a tendency to punish—a systems approach is required to ensure uniform approaches to maximum reporting and a fair analysis of contributing gaps in patient safety.

Quality and Safety Education for Nurses (QSEN) defines the patient safety competency as: “minimizes risk of harm to patients and providers through both system effectiveness and individual performance” (Cronenwett, 2007, p. 128). The QSEN competency definition expands the competency to include both individual and system foci. When examining nurses' understanding of updated components of patient safety, it is helpful to consider the requisite knowledge, skills, and attitudes (KSAs) that are needed in today's practice. QSEN operationalizes the patient safety competency into KSAs for the continuing education of nurses. Perhaps most notable in QSEN's KSAs for patient safety is the explicit inclusion of just culture and an appreciation for complex systems. QSEN KSAs for the patient safety competency are listed in Table 1.

Quality and Safety Education for Nurses Patient Safety Competency Knowledge, Skills, and Attitudesa

Table 1:

Quality and Safety Education for Nurses Patient Safety Competency Knowledge, Skills, and Attitudes

The Role of Just Culture

A vital part of improving patient safety is accurate tracking of adverse events and near-misses. If errors are not reported, targeted improvements are hard to implement. Nurses' underreporting of errors is a well-documented phenomenon, with fear of punishment being a leading reason for lack error reporting by nurses (Dyab, Elkalmi, Bux, & Jamshed, 2018). Errors that are not reported cannot contribute to better understanding of what contributes to errors in care. Thus, nurses' understanding of just culture is crucial to efforts to improve patient safety.

Health care systems are moving toward just culture, where error analysis is not solely about identifying individuals at fault but also focuses on understanding how an error occurred. A just culture paradigm encourages a standard of accountability—it is neither punitive nor blame free. Just culture shifts the focus from errors and outcomes to examining how to improve system design to avoid future errors (Marx, 2019). In working to improve patient safety, nurses can analyze the presence of just culture in their organizations. In the development of a just culture assessment tool, Petschonek et al. (2013) identified six core dimensions necessary for just culture: balance, trust, openness of communication, quality of the event-reporting process, feedback and communication about events, and overall goal of continuous improvement. An effective analysis of just culture assesses the degree to which these six dimensions are present in a health care system. Table 2 provides a definition of each dimension.

Just Culture Dimensions and Definitionsa

Table 2:

Just Culture Dimensions and Definitions

A Test of Just Culture—Reporting Near-Misses

One of the best measures for nurses to assess whether their agency has not only adopted a just culture approach but has enlivened just culture is to examine how near-misses are handled. A near-miss is an error that is caught before it reaches the patient or causes harm (World Health Organization, 2005). Only when nurses feel supported and safe in reporting adverse incidents are near-misses reported. A recent review of barriers to reporting errors and near-misses emphasized that the most important element in facilitating reporting is a nonblaming, nonpunitive, and nonfearful learning culture at both the unit and organizational levels (Vrbnjak, Denieffe, O'Gorman, & Pajnkihar, 2016). Just culture models support this shift away from punishment and toward solution-oriented, effective reporting systems (Vrbnjak et al., 2016). Errors that do not reach the patient are rich opportunities to improve care and care systems.

Just Culture Improves Improvement

When gap analysis around an error include systems analyses, opportunities exist to address the elements of the underlying health care system that contributed to the error. For example, a common recommendation in how to improve medication administration errors has focused on remediation of the nurse and nurse practice (Coyne, Needham, & Rands, 2013). Recent recommendations on improving patient safety around medication administration reflect the appreciation that there are individual clinicians—as well as system contributors—to most errors. For example, the Agency for Healthcare Research and Quality recommends that along with nurses using the five rights in medication administration, other system-focused improvements should be standard in addressing medication administration safety:

  • Use of tall man lettering to decrease ambiguity around medications that look and sound alike.
  • Agencies use automated dispensing cabinets for high-risk medications.
  • Systems implement bar code medication administration.
  • Microsystems work to systematically decrease nurse interruptions during medication administration.
  • Units use smart infusion pumps as standard equipment (Patient Safety Network, n.d.).

Improvement of patient safety is best served when both individual nurse and system deficiencies are addressed.

Strategies for Teaching Just Culture

Journal Club

Ask your nurses to read David Marx's article, “Patient Safety and Just Culture” (Marx, 2019). This article provided excellent background, definitions, and applications of just culture. Discuss error reporting habits with your nurses. What are the barriers? What are the facilitators? Examine nurses' perception of blame and punishment in your system. By the end of this journal club, your nurses will appreciate that just culture improves patient safety in complex systems by supporting increased reporting of errors and near-misses.

Assessment of Just Culture in Unit

Nurses can assess the presence of just culture in their practice environment. After an assessment, educators can lead nurses through a prioritization process to address the most important areas of improvement for just culture on their unit. Assessment can be conducted through examining the following trends:

  • Do nurses feel there is balance in how errors are handled? Is there fair treatment related to errors?
  • Is there trust in the unit? Do nurses trust their supervisors and colleagues?
  • Do nurses experience open communication? Is error event information communicated with appropriate transparency to improve systems?
  • What do nurses think about the quality of event reporting? Are nurses given time to report errors, and is the system adequately monitored and maintained?
  • Do nurses receive adequate feedback? Once an error or near-miss is reported, do managers follow up?
  • Do nurses believe there is a commitment to continuous improvement?

Important patient safety lessons can be learned from errors that do not reach the patient. When nurses work to increase the reporting of near-misses, they are actively working to develop safer systems. Educators can teach nurses about just culture through a staff activity of examining the existing policy for reporting near-misses. Do nurses know what a near-miss is? Does a policy for reporting near-misses exist? If a policy does not exist, educators can use an education session to garner ideas about important elements to develop a policy on reporting near-misses.


  • Balas, M.C., Scott, L.D. & Rogers, A.E. (2004). The prevalence and nature of errors and near errors reported by hospital staff nurses. Applied Nursing Research, 17, 224–230. doi:10.1016/j.apnr.2004.09.002 [CrossRef]15573330
  • Coyne, E., Needham, J. & Rands, H. (2013). Enhancing student nurses' medication calculation knowledge; Integrating theoretical knowledge into practice. Nurse Education Today, 33, 1014–1019. doi:10.1016/j.nedt.2012.04.006 [CrossRef]
  • Cronenwett, L. (2007). Quality and Safety Education for Nurses. Nursing Outlook, 55, 122–131. doi:10.1016/j.outlook.2007.02.006 [CrossRef]17524799
  • Dyab, E.A., Elkalmi, R.M., Bux, S.H. & Jamshed, S.Q. (2018). Exploration of nurses' knowledge, attitudes, and perceived barriers towards medication error reporting in a tertiary health care facility: A qualitative approach. Pharmacy, 6, 120. doi:10.3390/pharmacy6040120 [CrossRef]
  • Harmer, B. & Henderson, V. (1955). Textbook of the principles and practice of nursing. New York, NY: Macmillan.
  • Institute of Medicine. (2000). To err is human: Building a safer health system. Washington, DC: National Academies Press.
  • Landrigan, C.P. (2010). Temporal trends in rates of patient harm resulting from medical care. The New England Journal of Medicine, 363, 2124–2134. doi:10.1056/NEJMsa1004404 [CrossRef]21105794
  • Marx, D. (2019). Patient safety and the just culture. Obstetrics and Gynecology Clinics of North America, 46, 239–245. doi:10.1016/j.ogc.2019.01.003 [CrossRef]31056126
  • Patient Safety Network. (n.d.). Medication errors and adverse drug events. Retrieved from
  • Petschonek, S., Burlison, J., Cross, C., Martin, K., Laver, J., Landis, R.S. & Hoffman, J.M. (2013). Development of the just culture assessment tool: Measuring the perceptions of health-care professionals in hospitals. Journal of Patient Safety, 9, 190–197. doi:10.1097/PTS.0b013e31828fff34 [CrossRef]24263549
  • Rafter, N., Hickey, A., Condell, S., Conroy, R., O'Connor, P., Vaughan, D. & Williams, D. (2015). Adverse events in healthcare: Learning from mistakes. QJM, 108, 273–277. doi:10.1093/qjmed/hcu145 [CrossRef]
  • Vrbnjak, D., Denieffe, S., O'Gorman, C. & Pajnkihar, M. (2016). Barriers to reporting medication errors and near misses among nurses: A systematic review. International Journal of Nursing Studies, 63, 162–178. doi:10.1016/j.ijnurstu.2016.08.019 [CrossRef]27637011
  • World Health Organization. (2005). World alliance for patient safety: WHO draft guidelines for adverse event reporting and learning systems: From information to action. Retrieved from

Quality and Safety Education for Nurses Patient Safety Competency Knowledge, Skills, and Attitudesa


Examine human factors and other basic safety design principles, as well as commonly used unsafe practices (e.g., work-arounds and dangerous abbreviations).

Describe the benefits and limitations of selected safety-enhancing technologies (e.g., barcodes, computer provider order entry, medication pumps, and automatic alerts/alarms).

Discuss effective strategies to reduce reliance on memory.

Demonstrate effective use of technology and standardized practices that support safety and quality.

Demonstrate effective use of strategies to reduce risk of harm to self or others.

Use appropriate strategies to reduce reliance on memory (e.g., forcing functions, checklists).

Value the contributions of standardization/reliability to safety.

Appreciate the cognitive and physical limits of human performance.

Delineate general categories of errors and hazards in care.

Describe factors that create a culture of safety (e.g., open communication strategies and organizational error reporting systems).

Communicate observations or concerns related to hazards and errors to patients, families, and the health care team.

Use organizational error reporting systems for near-miss and error reporting.

Value own role in preventing errors.

Describe processes used in understanding causes of error and allocation of responsibility and accountability (e.g., root cause analysis and failure mode effects analysis).

Participate appropriately in analyzing errors and designing system improvements.

Engage in root cause analysis rather than using blame when errors or near misses occur.

Value vigilance and monitoring (even of one's own performance of care activities) by patients, families, and other members of the health care team.

Discuss potential and actual impact of national patient safety resources, initiatives, and regulations.

Use national patient safety resources for own professional development and to focus attention on safety in care settings.

Value relationship between national safety campaigns and implementation in local practices and practice settings.

Just Culture Dimensions and Definitionsa

BalanceOne's perception of fair treatment within the organization as it is related to error, error reporting, and the organization's systems approach to medical error.
TrustThe extent to which individuals trust the organization, their supervisors, and their coworkers.
Openness of communicationThe willingness of individuals to communicate event information upward to supervisors and hospital administrators, (e.g., willingness to reveal events, share events information, and make suggestions for improvement within the unit or the organization).
Quality of the event reporting processOne's perceived quality of the event reporting system (which includes the process of entering reports and the ability to follow up on these reports), whether employees are provided time to report, and to what extent the employees believe that the reporting system is monitored and maintained.
Feedback and communicationOne's belief regarding whether the organization does an effective job of sharing information about the events and the outcome of evaluating events.
Overall goal of continuous improvementOne's belief that the organization as a whole demonstrates a goal of continuous improvement, characterized by a willingness to learn from events and make improvements to the system.

Dr. Armstrong is Professor, Oregon Health & Science University School of Nursing, Portland, Oregon.

The author has disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Gail Armstrong, PhD, DNP, ACNS-BC, RN, CNE, Professor, Oregon Health & Science University School of Nursing, 3455 SW US Veterans Hospital Rd., Portland, OR 97239; e-mail:


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