A transformational shift toward a just culture.

A health system implemented a comprehensive just culture initiative to strengthen patient safety and improve staff confidence in reporting errors and near misses. Guided by stakeholder engagement, multidisciplinary collaboration, leadership support, staff education, champion development, and the introduction of a just culture decision-making algorithm, the organization sought to foster accountability, learning, and psychological safety. A pilot implementation was followed by systemwide adoption across 10 hospitals. Evaluation demonstrated significant increases in incident reporting rates and improvements in patient safety culture survey domains, suggesting greater transparency and engagement in safety practices. The initiative supported a sustained organizational shift toward a stronger culture of safety.