Impact of Just Culture Implementation on Safety Event Reporting in Critical Care Units in an Academic Medical Center

Background: This article describes the journey of a hospital system, specifically within the intensive care units, related to implementing a Just Culture program. It focuses on the process, strategies implemented, and challenges/roadblocks. The results of the survey’s impact on patient safety and overall safety event reporting will be shared. The article will end with tips for success. Methods: The quality improvement project focused on a comprehensive approach to Just Culture using the Institute for Healthcare Improvement Plan, Do, Study, Act methodology. Results: Impact was measured using the CT2023 Agency for Research & Quality Patient Safety Survey, compared with the calendar year (CY) 2025 results, to understand the extent to which the organizational culture supported patient safety. An improvement was noted in the response to the error domain in the critical care units. The overall domain increased from 54.58% (2023) to 59% (2025). Safety event reporting was compared from CY2023 to CY2024. A t test was utilized to evaluate statistical significance with reporting practices. There was a statistically significant improvement in reporting ( P = .00000009). Conclusions: Implementation of Just Culture statistically impacted the critical care units throughout the hospital.