We are human.


People make mistakes. That's an inescapable reality. Choosing how we react to our mistakes is another matter entirely. 

What did you do the last time you made an error? How did you feel? How did your organization react?

In 2013, UCSF Children's Hospital gave Pablo Garcia a massive overdose of an antibiotic. This is a world renowned institution. Their staff represent the best and the brightest in health care. How could this happen? After the incident, Bob Watchter published the details of this error and wrote about the many root causes identified. That story illustrates many aspects of how just culture applies in medicine. 

As you read Watcher's story, think about whether the reaction shows retributive or restorative just culture.

A retributive just culture asks: Which rule is broken? Who did it? How bad was the breach, and what should the consequences be? Who gets to decide this?

A restorative just culture asks: Who is hurt? What do they need? Whose obligation is it to meet that need? How do you involve the community in this conversation?

-Sidney Dekker

In this article, we see several victims. There are the first victims - Pablo Garcia and his family, who were harmed by this error. They were hurt and their needs must be addressed.

There are also the second victims - the resident who ordered the medication, the pharmacist who filled it, the nurse who administered it. None of those second victims came to work and said "I'm going to hurt someone today." They were all doing their best in a broken system. They were also hurt. 

Retributive justice serves neither first nor second victims. Restorative justice seeks to heal both. A restorative just culture shines a light on suffering, takes responsibility, and makes amends.

We can restore our joy through justice. The journey is long, the path is murky, but if we continue to hold up the light and keep moving, we'll get there.