Rooting an Error Review Process in Just Culture: Lessons Learned




patient safety, safety culture, psychological safety, just culture, language of caring, safety event review


Just Culture Visual Abstract

Repeated culture of safety surveys of the nursing staff at Children’s Hospital of Philadelphia’s main campus demonstrated lagging scores in the domain of nonpunitive responses to error. We had tried for many years to address the problem using a variety of strategies, including small group training sessions on just culture for staff and leaders, but had met with limited success. Finally, in 2015, we committed ourselves to trying something genuinely different—even perhaps disruptive—that might actually shift our stagnant metrics. Our novel, multifaceted program, implemented over a two-year period, yielded a 13% increase in staff rating scores that we have been able to sustain over the subsequent two-year period. The design and rollout of our program was neither simple nor smooth, but it has taught us valuable lessons about realistic, operational implementation of principles of psychological safety in a large and complex clinical organization. In this paper, we describe our program and the lessons learned in the journey from idea inception to post-implementation.

Author Biographies

Kristin Neiswender, RN, MSN, Children’s Hospital of Philadelphia

Kristin Neiswender has been a senior patient safety manager at Children’s Hospital of Philadelphia since 2009. In this role, she is responsible for event reviews and safety-related education, and she co-leads an organizational refresh of safety behaviors. She also oversees several safety culture–based programs, including Just Culture and Good Catch. She has her Bachelor of Science in nursing from Penn State University and her Master of Science in nursing from the University of Phoenix. She holds certifications in TeamSTEPPS, psychological safety, and patient safety. Before her safety career, she was a staff nurse for 20 years.

Ana Figueroa-Altmann, DM, RN, Children’s Hospital of Philadelphia

Ana Figueroa-Altmann is senior director of Nursing Safety, Regulatory and Performance Improvement at Children’s Hospital of Philadelphia. She facilitates, implements, and supervises program design of regulatory preparedness and safety and quality for the enterprise of the nursing department. Preceding this role, Figueroa-Altmann had a combined 10 years of experience as a nurse manager of a medical unit and critical care unit. She earned her Bachelor of Science in nursing from Villanova University, her Master of Science in nursing from Drexel University, and her doctorate of management from the University of Phoenix.

Kristin Granahan, MSN, RN, Children’s Hospital of Philadelphia

Kristin Granahan is a safety quality specialist, supporting the Department of Nursing at the Middleman Family Pavilion, Children’s Hospital of Philadelphia, King of Prussia campus. In her role, she is a department program leader for patient safety and quality improvement initiatives to improve patient outcomes. Granahan earned her Bachelor of Science in nursing from the Pennsylvania State University and her Master of Science in nursing from Wilmington University.

Darlene Barkman, MA, Children’s Hospital of Philadelphia

Darlene Barkman ( is currently an education specialist within the department of Medical Ethics at Children’s Hospital of Philadelphia (CHOP). In this role, she collaborates to create, deliver, and facilitate ethics educational content directed to all levels of CHOP staff, with the primary objective of fostering and facilitating ethical conduct both as a cultural norm and as a learnable set of skills. Previously at CHOP, Barkman was a family consultant. In this role, Barkman led the advancement of family-centered care within the CHOP organization and worked strategically with teams across the hospital to help ensure that new systems and programs reflected the most critically important things to support patients and their families.


David DS. The Association Between Organizational Culture and the Ability to Benefit From “Just Culture” Training. J Patient Saf. 2019;15(1). doi:10.1097/pts.0000000000000561

Paradiso L, Sweeney N. Just Culture. Nurs Manage. 2019;50(6):38-45. doi:10.1097/

Barkell NP, Snyder SS. Just Culture in Healthcare: An Integrative Review. Nurs Forum. 2020;56(1):103-111. doi:10.1111/nuf.12525

Shabel W, Dennis JL. Missouri’s Just Culture Collaborative. J Healthc Risk Manag. 2012;32(2):38-43. doi:10.1002/jhrm.21093

Korkis L, Ternavan K, Ladak A, Maines M, Ribeiro D, Hickey S. Mentoring Clinical Nurses Toward a Just Culture. J Nurs Admin. Published online July 2019:1. doi:10.1097/nna.0000000000000772

Language of Caring. Language of Caring Philosophy. Language of Caring website. Accessed December 28, 2021.

Red doctor holding up a shield to three pointing blue hands.



How to Cite

Neiswender, K., Figueroa-Altmann, A., Granahan, K., & Barkman, D. (2022). Rooting an Error Review Process in Just Culture: Lessons Learned. Patient Safety, 4(3), 34–38.



Patient Safety Initiatives
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