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Just Culture

Commitment 2 of the HSE Patient Safety Strategy (2019-2024) outlines our ambition for a compassionate, just, fair and open culture in the HSE and states that “Staff must be actively encouraged to speak up for safety, feel psychologically safe, be involved in decisions which affect the safe delivery of care and be provided with the skills, support and time to engage in patient safety improvement initiatives”.

What is Just Culture?

The HSE Incident Management Framework (2020) defines Just Culture as one which refers to a values based supportive model of shared accountability. It states that individual staff should not be held accountable for system failings over which they have no control. Instead, organisations need to encourage staff to report such incidents and near-misses and apply system-learning to improve patient safety. The HSE Incident Management Framework (2020) also acknowledges that within a Just Culture, acts of deliberate harm and complete disregard of policies and procedures without due consideration by staff are not acceptable which is equally important to maintain patient safety. A just culture approach is key in gaining a shared understanding of how safety is achieved within any complex organisation.

Our Commitment

The HSE is committed to creating an environment within the HSE that encourages staff to speak up whether this involves the reporting of incidents or raising issues that pose a risk to the safety of service users, without fear of reprisal. It is essential that our staff feel confident to report incidents so that there is learning from such events and the healthcare system is improved.

The HSE has recently established a working group to support a consistent and evidence based strategic approach to the implementation of Just Culture and the application of fair, appropriate and shared accountability when patient safety incidents arise. This work group includes membership from all levels of the HSE, clinical and patient representatives and academic experts in the field of Just Culture. The group is chaired by the Assistant National Director for QPS Incident Management within the National Quality and Patient Safety Directorate and will report to the Chief Clinical Officer of the HSE.

In addition, Just Culture has been included in the Serious Incident Management Team (SIMT) training and Systems Analysis Review training currently being delivered by the Incident Management Team.

Relevant Documents


23rd May, 2023: Building a Just Culture in Healthcare: a HSE Dialogue, Croke Park Conference Centre, Dublin

Additional Resources

Further information

Contact: Samantha Hughes, QPS Incident Management