Just Culture in Practice: International Experiences and Perspectives for the Swiss Healthcare System (Part 5)

An AI tool was used to translate this article from German.

Following the theoretical foundations in Part 1, the in-depth look at behavioural classification in Part 2 , the implementation roadmap in Part 3 and the overview of digital reporting systems in Part 4, this concluding part of the series focuses on international experiences with the implementation of a just culture.

While the previous articles primarily dealt with the conceptual foundations and practical tools of Just Culture in the Swiss context, the focus is now on the country’s borders. Switzerland is not alone in the question of how Just Culture can be systematically implemented. In recent years, different countries have developed and tested different approaches – with different focuses, but also with valuable learning experiences.

This part therefore examines: Which approaches to error management in the healthcare sector have proven successful in other countries? What challenges have been identified? What success factors can be derived? And what development opportunities does this open up for the Swiss healthcare system with its specific framework conditions such as multilingualism and federal structure?

The analysis is based on selected international expert sources as well as on the feasibility study by the FOPH and the Federal Quality Commission on Just Culture in the Swiss healthcare system, which explicitly places the initial situation in Switzerland in an international context (Leibold & Fridrich, 2024).

The evolution of the Just Culture concept

Before we turn to the concrete country examples, it is worth taking a brief look at the conceptual development of Just Culture in recent years. This is because the approaches that are being discussed and implemented internationally today are in some cases significantly different from earlier concepts.

Today, Just Culture is no longer understood as just a question of a fair response to mistakes, but increasingly as part of a broader safety and learning culture. The focus is on the idea that organizations should react to incidents neither in a purely punitive nor purely without consequences, but in a differentiated, comprehensible and learning-oriented way. This is linked to the question of how responsibility, openness and the ability to improve can actually be shaped in the everyday life of health organizations.

Boskeljon-Horst et al. (2024) describe several conditions that are conducive to successful implementation in the context of a restorative further development of Just Culture. This includes, in particular, the way managers react to incidents, the basic attitude to responsibility, the handling of external pressure, the support of affected employees and the creation of spaces for honest disclosure. This perspective shifts the focus from the mere classification of individual behaviors to the question of how organizations combine learning, fairness and restoration in their daily actions.

In this way, Just Culture is directly linked to concepts such as psychological safety, error culture and learning culture. This is particularly important for error management in the healthcare sector: where employees conceal incidents or near misses for fear of sanctions, risks remain hidden. Where openness is possible, reporting and learning systems, CIRS reporting systems and quality management can only be effective.

The Swiss starting position

In order to assess the relevance of international experience for Switzerland, it is first necessary to take a look at the current situation in the Swiss healthcare system. The feasibility study by Leibold and Fridrich (2024) provides a sound basis for this.

On behalf of the Swiss Patient Safety Foundation and the Federal Office of Public Health, the current situation of error management in the Swiss healthcare system was examined. The study concludes that Just Culture is still in an early stage of development in the Swiss healthcare system as a whole. Although individual initiatives, discussion approaches and institutional experiences exist, there is no evidence of broad-based, systematically anchored implementation so far. The authors point to differences between institutions, regions and hierarchical levels. French-speaking Switzerland in particular appears in the study as an area in which certain concepts and instruments are already further developed or more visibly anchored than in other parts of the country.

At the same time, the study also identifies existing strengths. Among other things, committed professional associations, individual pioneering hospitals with established CIRS reporting systems with clinical quality and risk management as well as a fundamentally high level of awareness of patient safety are mentioned. However, structural challenges are also evident: the lack of a national strategy and legal clarity, inconsistent standards between the cantons, differences between management and frontline employees in the perception of safety culture, and gaps in the systematic integration of Just Culture into education and training.

Especially in the federal context, this starting point is ambivalent. On the one hand, the Swiss system allows institutional and regional adjustments, but on the other hand, it makes it more difficult to develop common minimum standards and binding guidelines. The study therefore emphasizes the importance of legal bases, national coordination, institutional leadership and a stronger anchoring of Just Culture and Human Factors in education and development structures (Leibold & Fridrich, 2024).

This analysis shows that the Swiss healthcare system entails both flexibility and fragmentation. A successful just-culture implementation could therefore benefit from an approach that combines national coordination with local autonomy – not as rigid centralization, but as an aligned framework for patient safety, healthcare error management, and learning culture.

International approaches and experiences

The implementation of Just Culture takes place internationally in different ways and with different focuses. While some countries rely more on legal anchoring and national coordination, others develop decentralised approaches with an emphasis on local autonomy. Still others focus on structured decision-making tools, overarching reporting and learning structures, or restorative and learning-oriented practices.

The following examples from Denmark, England, Australia/New Zealand and Sweden illustrate various strategies for reporting systems, CIRS-related reporting and learning systems, error culture, risk and quality management. This selection does not claim to be complete. Rather, it is intended to illustrate how differently Just Culture can be institutionally designed. Each of these countries has specific framework conditions – from system architecture to legal foundations and cultural peculiarities – that must be taken into account when interpreting the results.

For Switzerland, with its federal system, multilingual context and decentralised health care, those experiences that show how national coordination can be combined with local implementation are of particular interest.

Denmark

Denmark introduced a legal obligation to report incidents and near misses in the healthcare sector in 2004, combined with explicit protection from prosecution for reporters in the absence of reckless behaviour. This approach to error and risk management in healthcare is internationally considered groundbreaking (Edmondson, 2018). The sanction-free and confidential reporting system enables employees in hospitals and clinics to report security-relevant events without fear of consequences – even completely anonymously if necessary. While all data is processed anonymously at the national level, confidential reporting at the hospital level allows local quality managers to ask important questions for a well-founded error analysis.

According to the annual report of DPSD-Årsberetning 2024 – the Danish Patient Safety Authority – the number of reported incidents in the Danish Patient Safety Registry (DPSD) increased from about 294,000 in 2020 to 489,361 in 2024 – an increase of almost 200,000 reports in four years. Of the total of 489,361 reports, 361,511 were recorded as “summary reporting”. This is a simplified form of collective reporting in which several similar events or near misses are documented together, provided that they have not led or could have led to serious or fatal consequences (Danish Patient Safety Authority, 2024). The agency’s director, Anette Lykke Petri, describes this increase and the high number of reports as positive, as they reflect an increased learning orientation in defect and quality management. However, she also emphasizes that simply reporting is not enough – it is crucial to learn from mistakes and implement measures to prevent new events.

High registration figures do not automatically mean a high level of security. However, they can indicate that reporting and learning systems are actually being used and that incidents and near misses become visible. This is particularly important for a resilient learning culture. What is not reported can neither be systematically analysed nor translated into improvement measures. The Danish example therefore shows above all that reporting systems can be effective if they are anchored in the organization, can be used in everyday life and are trustworthy for employees.

At the same time, the Danish approach makes it clear that functioning reporting and learning systems depend on psychological safety. Employees must be able to assume that reports do not reflexively lead to blame, but are part of a serious learning and improvement process. A legal obligation can therefore significantly increase the willingness to report incidents and near misses if it is combined with clear protective provisions, psychological safety in the workplace and practicable implementation. In this respect, Denmark is interesting less because of individual key figures than because of the institutional normalization of error messages in everyday clinical practice.

England

England, in comparison, has a slightly different focus. Since 2025, the Being Fair tool has been available there as a structured decision-making tool that can be used in the context of patient safety incidents when questions arise about the behaviour or suitability of individual employees (NHS England, 2025).

This tool is neither a classic CIRS reporting system nor a substitute for other reporting and learning systems. Rather, its purpose is to make decisions after an incident more comprehensible, consistent, and fair. It is intended to help managers and organizations distinguish between individual and systemic factors and not to judge employees hastily or inappropriately after a safety-relevant event.

This approach is relevant to the discussion about Just Culture for several reasons. First, it shows that fair responses depend not only on a general attitude, but also on structured procedures and clear criteria. Secondly, it becomes apparent that patient safety, personnel management and regulatory issues are often closely linked in practice. Thirdly, the example illustrates that Just Culture is not necessarily implemented via a single comprehensive programme, but also via targeted instruments that address the interfaces between quality management, leadership and error management.

In addition, in England, the Learn from Patient Safety Events (LFPSE) is relevant as a national NHS system for recording and analysing patient safety events. LFPSE has replaced the former National Reporting and Learning System (NRLS) and now serves as a national infrastructure to systematically record and evaluate patient safety events and make them usable for local and national learning (NHS England, 2025).

England thus illustrates how structured decision-making processes and national learning infrastructure can coexist and together contribute to a fairer and more systematic safety culture. Of particular interest to the Swiss discussion is how a national database can be combined with local systems and a learning-oriented use of reported events.

Australia / New Zealand

In Australia, especially in New South Wales, the topic has been increasingly developed in recent years under the term “Restorative Just and Learning Culture”. The Clinical Excellence Commission NSW’s Guide to Co-developing a Restorative Just and Learning Culture (2024) describes an approach that thinks learning, relationship building and system improvement more closely together.

The focus is not only on the analysis of the incident, but also on the question of how to deal with the effects on all parties involved. This includes patients and relatives as well as employees and managers. The guide emphasizes psychological safety, cooperative development, appropriate responses after events, systematic learning, and the joint evaluation of experiences and outcomes.

This approach makes it clear that critical events have not only technical and organizational consequences, but also human consequences. Restorative approaches are therefore not to be understood as the opposite of classic error management, but as an extension of it: not only processes and root cause analyses, but also experiences, relationships and consequential burdens become the subject of organizational learning. This also includes targeted support for employees who are themselves significantly affected after a stressful event – an aspect that is often discussed under the term second victim or second victim support (Clinical Excellence Commission NSW, 2024; Boskeljon-Horst et al., 2024).

In addition, New Zealand can be used as an example of comprehensive learning from damaging events. In its overview of damage events in the health and disability sector, the Health Quality & Safety Commission (HQSC) shows that damage to care can have far-reaching effects on those affected, families and loved ones, employees and communities. The focus is less on a single key figure than on the fundamental perspective: Damage events are not only seen as isolated cases, but are understood as an occasion for systematic learning and the further development of patient safety (Health Quality & Safety Commission New Zealand, 2025).

For the Swiss, this approach is particularly interesting because it broadens the view beyond the individual institution and links Just Culture more closely with error culture, learning culture, psychological safety and personnel support. It is crucial not only that incidents are documented, but that the insights gained from them are also made usable for broader learning and improvement processes. Especially in complex organizations, this can help to anchor error management not only technically or formally, but also on a human and cultural level.

Sweden

The Swedish healthcare system follows a decentralized, legally regulated approach to error management, which is based on the Patient Safety Act. An important milestone was the National Patient Safety Initiative, launched in 2013, which was supported by the government and the Swedish Association of Municipalities SALAR (Anell et al., 2012). The aim was to create structured processes to support research and promote systematic learning from incidents and near misses in healthcare error management.

Sweden has deliberately dispensed with a central national database for uniform incident reporting of all hospitals and instead relies on regional reporting and learning systems. In addition, facilities are required to publish a standardized patient safety report annually. The analysis of these reports by Ridelberg et al. (2016) shows that they represent a wide range of structural, process and outcome elements and offer considerable potential for cross-organizational learning despite the decentralized organization.

For the Swiss discussion, Sweden is of particular interest from a systemic point of view. The decisive factor here is not so much a single instrument as the question of how patient safety can be further developed through institutional responsibility, lived reporting practice and continuous learning processes.

The tension between decentralisation and transparency is particularly relevant for Switzerland. In federal or regional systems, the question arises again and again as to how security development can be made binding without losing sight of local conditions. It is precisely this basic question that the Swiss feasibility study addresses when it emphasizes the importance of coordination, leadership and a reliable anchoring of Just Culture (Leibold & Fridrich, 2024).

Key success factors from an international perspective

Despite the differences in system architecture, legal frameworks and cultural contexts, some overarching success factors can be derived from international experience. These factors appear again and again in different countries and settings and seem to play a central role regardless of the specific implementation approach.

The following compilation is not intended as an exhaustive list, but as a synthesis of observable patterns that could be relevant for the Swiss discussion.

• Psychological safety as a basic requirement: Successful implementations emphasize the importance of an environment where employees can report and address mistakes, incidents, and near misses without fear of negative consequences. Psychological safety is thus an important basis for a constructive error culture, functioning CIRS reporting systems and effective quality and risk management in hospitals and clinics (Edmondson, 2018).
• Structured processes and clear criteria: Both the NHS Being Fair Tool and the structured approaches in Australia show that transparent decision-making processes can increase consistency and perceived fairness in the handling of incidents (NHS England, 2025a; Clinical Excellence Commission NSW, 2024).
• Systematic learning culture as well as reporting and learning systems: Successful implementations not only create reporting opportunities, but also structures to systematically learn from reported incidents and near misses and derive system improvements. CIRS reporting systems and other reporting and learning systems form the technological basis for this.
• Support for affected employees: The systematic support of employees after stressful events is not just an additional offer, but an important element of credible just-culture implementation. Restorative approaches in particular make it visible that fairness is not only expressed in the analysis of the causes, but also in dealing with the consequences of events, This applies in particular to employees who are themselves under a lot of stress after an incident and need targeted support in the sense of second victim support(Boskeljon-Horst et al., 2024; Clinical Excellence Commission NSW, 2024).
• Balance between national coordination and local autonomy: Countries with federal or decentralised healthcare systems face similar challenges to Switzerland. Successful approaches combine national standards and common guiding principles for error and risk management with local adaptability in hospitals, clinics and other care facilities (Leibold & Fridrich, 2024).

Possible development paths for Switzerland

The international experiences presented raise the question of what development opportunities could arise for the Swiss healthcare system. The feasibility study by Leibold and Fridrich (2024) provides a sound basis for this by analysing both the existing strengths and the existing challenges of the Swiss system.

The following considerations on the further development of error management in the healthcare sector are expressly not intended as a finished roadmap or binding recommendations, but as a basis for discussion for the various stakeholders in the Swiss healthcare system. Which of these options will be pursued as a priority, in what order and with what specific forms will have to be decided jointly by the stakeholders involved – the Confederation, the cantons, professional associations, institutions and others.

When considering these development opportunities, it must also be taken into account that the Swiss healthcare system has specific characteristics: the federal structure with strong cantonal autonomy, multilingualism, the diversity of the care landscape from university hospitals to smaller institutions, and the direct democratic decision-making processes. These framework conditions require approaches that bring standardization and local flexibility into a meaningful balance.

One possible development path concerns the creation of a more favourable legal and institutional framework. The feasibility study emphasizes the importance of clear legal bases, national coordination and reliable governance structures so that Just Culture is not limited to individual projects or committed institutions (Leibold & Fridrich, 2024).

Another option would be to develop a Swiss decision-making tool that would provide managers with practical support in making fair decisions after incidents. Such an instrument could be conceptually based on the English Being Fair Tool, but would have to be adapted to Swiss legal, institutional and linguistic conditions.

Selected hospitals or health associations could also test restorative practices, for example in the form of structured dialogues after critical events. Such approaches could help to anchor psychological safety, error culture and learning culture more firmly in everyday life, without automatically having to create a uniform national model.

Another development path concerns the establishment of systematic support structures for affected employees. Second victim support could gradually be integrated more strongly into quality management and existing support services, especially in larger institutions.

Finally, integration into education and training remains central. The feasibility study highlights that Just Culture and related topics such as human factors, leadership and safety culture should be more firmly anchored in curricula, leadership development and training. This is the only way to understand Just Culture as a component of professional practice in the long term – and not just as an isolated project.

The role of digital systems

In all the international approaches described above – whether in Denmark, England, Australia, New Zealand or Sweden – digital systems play a central supporting role. They form the technological infrastructure that makes it possible to put Just Culture principles into practice in everyday work. This is not primarily about technology as an end in itself, but about the question of how digital tools can support cultural and organizational change.

As already described in detail in Part 4 of our series , digital reporting systems and CIRS (Critical Incident Reporting Systems) form the technological infrastructure of a Just Culture. CIRS reporting systems in Switzerland such as H-CIRS Starter, H-CIRS Professional and H-CIRS Community can integrate Just Culture principles directly into workflows of hospitals and clinics and support structured analysis processes in error management in the healthcare sector. These reporting and learning systems thus enable a simple and systematic recording of incidents and near misses and contribute to increasing quality and patient safety in the Swiss healthcare system.

The integration of such CIRS reporting systems into a national strategy can facilitate implementation by technologically enabling low-threshold near-incident reporting, anonymity through anonymous reporting, structured analysis support, action management and transparency (Reason, 1997; Marx, 2001; Leibold & Fridrich, 2024).

Integration into existing quality systems

A recurring theme in the international experience is the importance of integrating Just Culture into existing structures and processes. Successful implementations are characterized by the fact that Just Culture is not established as an additional, separate project, but flows into all relevant areas of quality and error management as a consistent principle.

This inclusive approach prevents Just Culture from being perceived as an isolated initiative that exists alongside other quality and safety programs. Instead, it becomes the fundamental principle that shapes the way the organization deals with mistakes, learning, and improvement.

Just Culture should therefore not be understood as a separate project, but as an integral part of existing quality management systems, error management in healthcare and clinical risk management. This includes, for example, anchoring them in clinical guidelines and treatment pathways, embedding them in risk management, incident management and incident reporting, addressing them in management and employee interviews, and including patient feedback systems (Sammer et al., 2010). A constructive error and learning culture are central elements in this.

The research of Sammer et al. (2010) shows that organizations with a high patient safety culture and maturity integrate safety into all processes – not as an additional project, but as a fundamental cross-cutting issue. Psychological safety, error culture, learning culture and systematic reporting and learning systems form central cornerstones.

Conclusion

The consideration of international experiences with Just Culture implementation provides both encouraging indications and realistic assessments of the challenges. The examples presented from different countries and health systems show that a systematic development of an equitable safety culture is possible, but at the same time requires time, resources and the coordinated commitment of various actors.

International experience shows that Just Culture implementation is possible in various healthcare systems and brings measurable improvements in reporting and error culture, risk management, patient safety and employee satisfaction (Edmondson, 2018; Sammer et al., 2010; Boskeljon-Horst et al., 2024; Strametz et al., 2021).

For Switzerland, this means one thing above all: Just Culture is neither a single tool nor a short-term cultural project. It touches on error management in healthcare, patient safety, CIRS reporting systems, reporting and learning systems, risk management, psychological safety and quality management at the same time. This is precisely why it is worthwhile to develop in a differentiated way that takes international experience seriously without transferring it without reflection.

Conclusion of the series

This fifth part concludes our blog series on Just Culture in the Swiss healthcare system. Over the course of five articles, we have examined the topic from different perspectives: from the theoretical foundations and systemic security thinking to the differentiated consideration of behaviour and responsibility, a practice-oriented implementation roadmap and the role of digital CIRS reporting systems, as well as reporting and learning systems, to international experiences and possible development paths for Switzerland.

The series saw itself as a contribution to the expert discussion on just culture, error culture, learning culture and psychological safety in the Swiss healthcare system. It was aimed at specialists, managers and organisations that deal with safety culture, risk and quality management in practice. The aim was to make evidence-based knowledge on error and risk management in healthcare institutions, CIRS and patient safety accessible, to introduce international perspectives and to offer practical orientation for building a fair and learning-oriented safety culture – without claiming to be complete or conclusive instructions.

We would like to thank all readers for their interest in this important topic. The development of a fair safety culture is a continuous process that is supported jointly by many actors. We hope that this series could help to enrich the discussion and provide impetus for practice.

Disclaimer and classification

This article represents an exemplary selection of international approaches to the implementation of Just Culture and does not claim to be complete. The information presented is based on the sources available at the time of writing and has been compiled to the best of our knowledge and belief. They are for information and classification purposes only.

The international examples, statistics and development opportunities described in this article are not to be understood as concrete recommendations for action or binding guidelines. Each organization must consider its specific legal, organizational and cultural framework and seek professional, regulatory or legal advice if necessary.

References

Anell, A., Glenngård, A. H., & Merkur, S. (2012). Sweden: Health system review. Health Systems in Transition, 14(5), 1–159. https://iris.who.int/items/0275e67d-4472-4766-8d2f-b09c0911a17a

Boskeljon-Horst, L., Steinmetz, V., & Dekker, S. (2024). Restorative Just Culture: An exploration of the enabling conditions for successful implementation. Healthcare, 12(20), 2046. https://doi.org/10.3390/healthcare12202046

Clinical Excellence Commission. (2024). Guide to Co-developing a Restorative Just and Learning Culture (Version 2). NSW Health. https://www.cec.health.nsw.gov.au/__data/assets/pdf_file/0008/891728/Guide-to-Co-developing-a-Restorative-Just-and-Learning-Culture.pdf

Danish Patient Safety Authority. (2024). Dansk Patientsikkerhedsdatabase Årsberetning 2024. https://stps.dk/udgivelser/2025/apr/dpsd-aarsberetning-2024

Edmondson, A. C. (2018). The fearless organization: Creating psychological safety in the workplace for learning, innovation, and growth. John Wiley & Sons. https://www.wiley.com/en-us/The+Fearless+Organization%3A+Creating+Psychological+Safety+in+the+Workplace+for+Learning%2C+Innovation%2C+and+Growth-p-9781119477266

Health Quality & Safety Commission New Zealand. (2025). 2023/24 Health and Disability Sector Harm (Adverse) Events. https://www.hqsc.govt.nz/resources/resource-library/202324-health-and-disability-sector-adverse-events/

Leibold, A., & Fridrich, A. (2024). Just Culture feasibility study in the Swiss healthcare system. FOPH / Federal Quality Commission. https://www.bag.admin.ch/dam/de/sd-web/L3Js1MQhLoRj/20250805 Just Culture feasibility study in the Swiss Gesundheitswesen.pdf

Marx, D. (2001). Patient safety and the “just culture”: A primer for health care executives. Columbia University.

NHS England. (2025a). Being fair tool: Supporting staff following a patient safety incident. https://www.england.nhs.uk/publication/being-fair-tool/

NHS England. (2025b). Learn from Patient Safety Events (LFPSE) service. https://www.england.nhs.uk/patient-safety/learn-from-patient-safety-events-service/

Reason, J. (1997). Managing the risks of organizational accidents. Ashgate.

Ridelberg, M., Roback, K., Nilsen, P., & Carlfjord, S. (2016). Patient safety work in Sweden: Quantitative and qualitative analysis of annual patient safety reports. BMC Health Services Research, 16, 98. https://doi.org/10.1186/s12913-016-1350-5

Sammer, C. E., Lykens, K., Singh, K. P., Mains, D. A., & Lackan, N. A. (2010). What is patient safety culture? A review of the literature. Journal of Nursing Scholarship, 42(2), 156–165. https://doi.org/10.1111/j.1547-5069.2009.01330.x

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Related articles in this series:

• Part 1: Just Culture in the Swiss Healthcare System – Theoretical Foundations
• Part 2: Understanding Just Culture – The Three Behaviors and the View of the System
• Part 3: The Road to Just Culture – Practical Implementation Roadmap
• Part 4: Just Culture in Practice – Digital Reporting Systems as Tools of Safety Culture
• Part 5: International experiences and perspectives for Switzerland (this article)