Case Study:​ Just Culture Through A Systems Thinking Approach To Human Error​

May 6, 2026

This activity provides a comprehensive exploration of the modern approach to understanding and preventing medical errors. Using the Vaught-Murphy case as a foundational case study, this presentation challenges the traditional "bad apple" theory of blame and introduces a "systems approach" to safety. Participants will learn how systemic vulnerabilities in processes, technology, and culture are often the primary contributors to adverse events. The session delves into the core principles of a Just Culture, the critical role of psychological safety in error reporting, and the application of analytical models like the Swiss Cheese Model. The presentation concludes by equipping attendees with actionable strategies and leadership questions designed to foster a robust culture of safety and continuous improvement within their own organizations. Ultimately, this training aims to empower healthcare professionals to move beyond blame and contribute to building more resilient and safer patient care systems.

Target Audience

This activity provides continuing education for physicians, nurses, physician associates/physician assistants, pharmacists, pharmacy technicians psychologists, dentists, dental hygienists, dental technicians, occupational therapists, occupational therapy assistants, healthcare executives, physical therapists, and physical therapist assistants across the Military Health System (MHS). A certificate of attendance is available for other attendees.

Learning Objectives

  1. Define Just Culture.
  2. Identify Systemic Failures in the Vaught-Murphy case.
  3. Discuss How a Systems Approach can increase Patient Safety.
  4. Explain the Role of Psychological Safety in an Organization.
  5. Outline the Consequences of Criminalization of Medical Errors.
  6. Apply a Systems Model (Swiss Cheese Model) to a sentinel event.
  7. Identify Leadership Questions and Actions that Foster a Just Culture 8. Identify Actionable Steps to Enable Just Culture.
    Course summary
    Available credit: 
    • 1.00 AAPA

      DHA J-7 CEPO has been authorized by the American Academy of Physician Associates (AAPA) to award AAPA Category 1 CME credit for activities planned in accordance with AAPA CME Criteria. This activity is designated for 1.00 hours of AAPA Category 1 CME credits. Approval is valid until Wednesday, May 20, 2026 - 11:59pm ET. PAs should only claim credit commensurate with the extent of their participation.

    • 1.00 ACCME Non-Physician CME Credit

      DHA J-7 CEPO is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing education. ACCME Non-Physician CME Credit providers will be provided a certificate of participation for educational activities certified for AMA PRA Category 1 Credit™. ACCME Non-Physician CME Credit providers may receive a maximum of 1.00 hours for completing this activity.

    • 1.00 ACHE

      By attending this program offered by DHA J-7 CEPO, participants may earn up to 1.00 American College of Healthcare Executives (ACHE) Qualified Education hours toward initial certification or recertification of the Fellow of the American College of Healthcare Executives (FACHE) designation. Participants in this program who wish to have the continuing education hours applied toward ACHE Qualified Education credit must self-report their participation. To self-report, participants must log into their MyACHE account and select ACHE Qualified Education Credit.

    • 1.00 ACPE-Pharm

      UAN: JA4008136-0000-26-074-L99-P
      No valid paper/electronic statement of credit will be offered. DHA J-7 CEPO is accredited by the American Council for Pharmacy Education (ACPE) to provide continuing education for Pharmacists. This knowledge-based activity will provide a maximum of 1.00 contact hours of pharmacy continuing education credit. Participant CE records will be electronically communicated to CPE Monitor. There is no cost to participate in this activity.

    • 1.00 ACPE-Tech

      UAN: JA4008136-0000-26-074-L99-T
      No valid paper/electronic statement of credit will be offered. DHA J-7 CEPO is accredited by the American Council for Pharmacy Education (ACPE) to provide continuing education for Pharmacy Technicians. This knowledge-based activity will provide a maximum of 1.00 contact hours of pharmacy continuing education credit. Participant CE records will be electronically communicated to CPE Monitor. There is no cost to participate in this activity.

    • 1.00 ADA CERP

      DHA J-7 CEPO is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education (CDE). ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to the Commission for Continuing Education Provider Recognition at ADA.org/CERP. 

      DHA J-7 CEPO designates this activity for 1.00 continuing education credits.

    • 1.00 AMA PRA Category 1 Credit™

      DHA J-7 CEPO is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. 

      DHA J-7 CEPO designated this Course for a maximum of 1.00 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

    • 1.00 ANCC

      DHA J-7 CEPO is accredited by the Joint Accreditation/Interprofessional Continuing Education (IPCE) to provide this Continuing Nursing Education Course for a maximum of 1.00 ANCC contact hours. Nurses should only claim credit commensurate with the extent of their participation in the activity.

    • 1.00 AOTA

      DHA J-7 CEPO is an American Occupational Therapy Association (AOTA) Approved Provider of professional development (PD). PD activity approval ID# 16104. This Distance Learning-Interactive course is offered at 0.1 CEUs, introductory, OT service delivery, professional issues, foundational knowledge. AOTA does not endorse specific course content, products, or clinical procedures.

    • 1.00 APA

      Continuing Education (CE) credits for psychologists are provided through the co-sponsorship of the American Psychological Association (APA) Office of Continuing Education in Psychology (CEP). The APA CEP Office maintains responsibility for the content of the programs. Participants may earn 1.00 CE credits for completing this activity.

    • 1.00 APTA

      DHA J-7 CEPO is an American Physical Therapy Association (APTA) Approved Provider of continuing education. This activity was planned by and for the health care team, and learners will receive 0.1 APTA CEUs. The assignment of APTA CEUs does not imply endorsement of specific course content, products, or clinical procedures by APTA. APTA CEUs are accepted by most state PT licensing boards. Learners are encouraged to check with their local chapter or state board to ensure that they accept APTA accredited courses for licensure renewal.

    • 1.00 Attendance
    • 1.00 IPCE

      In support of improving patient care, DHA J-7 CEPO is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. This activity was planned by and for the healthcare team, and learners will receive 1.00 Interprofessional Continuing Education (IPCE) credits for learning and change.

    Course opens: 
    04/20/2026
    Course expires: 
    05/20/2026
    Event starts: 
    05/06/2026 - 9:00am EDT
    Event ends: 
    05/06/2026 - 10:00am EDT
    Add to calendar: 
    Virtual - MS Teams

    MAJ Artinsia Shakir, DNP, AGACNP, CCM. Presenter has no relevant financial or non-financial relationship(s) relating to the course content or with ineligible companies to disclose..

    Available Credit

    • 1.00 AAPA

      DHA J-7 CEPO has been authorized by the American Academy of Physician Associates (AAPA) to award AAPA Category 1 CME credit for activities planned in accordance with AAPA CME Criteria. This activity is designated for 1.00 hours of AAPA Category 1 CME credits. Approval is valid until Wednesday, May 20, 2026 - 11:59pm ET. PAs should only claim credit commensurate with the extent of their participation.

    • 1.00 ACCME Non-Physician CME Credit

      DHA J-7 CEPO is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing education. ACCME Non-Physician CME Credit providers will be provided a certificate of participation for educational activities certified for AMA PRA Category 1 Credit™. ACCME Non-Physician CME Credit providers may receive a maximum of 1.00 hours for completing this activity.

    • 1.00 ACHE

      By attending this program offered by DHA J-7 CEPO, participants may earn up to 1.00 American College of Healthcare Executives (ACHE) Qualified Education hours toward initial certification or recertification of the Fellow of the American College of Healthcare Executives (FACHE) designation. Participants in this program who wish to have the continuing education hours applied toward ACHE Qualified Education credit must self-report their participation. To self-report, participants must log into their MyACHE account and select ACHE Qualified Education Credit.

    • 1.00 ACPE-Pharm

      UAN: JA4008136-0000-26-074-L99-P
      No valid paper/electronic statement of credit will be offered. DHA J-7 CEPO is accredited by the American Council for Pharmacy Education (ACPE) to provide continuing education for Pharmacists. This knowledge-based activity will provide a maximum of 1.00 contact hours of pharmacy continuing education credit. Participant CE records will be electronically communicated to CPE Monitor. There is no cost to participate in this activity.

    • 1.00 ACPE-Tech

      UAN: JA4008136-0000-26-074-L99-T
      No valid paper/electronic statement of credit will be offered. DHA J-7 CEPO is accredited by the American Council for Pharmacy Education (ACPE) to provide continuing education for Pharmacy Technicians. This knowledge-based activity will provide a maximum of 1.00 contact hours of pharmacy continuing education credit. Participant CE records will be electronically communicated to CPE Monitor. There is no cost to participate in this activity.

    • 1.00 ADA CERP

      DHA J-7 CEPO is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education (CDE). ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to the Commission for Continuing Education Provider Recognition at ADA.org/CERP. 

      DHA J-7 CEPO designates this activity for 1.00 continuing education credits.

    • 1.00 AMA PRA Category 1 Credit™

      DHA J-7 CEPO is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. 

      DHA J-7 CEPO designated this Course for a maximum of 1.00 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

    • 1.00 ANCC

      DHA J-7 CEPO is accredited by the Joint Accreditation/Interprofessional Continuing Education (IPCE) to provide this Continuing Nursing Education Course for a maximum of 1.00 ANCC contact hours. Nurses should only claim credit commensurate with the extent of their participation in the activity.

    • 1.00 AOTA

      DHA J-7 CEPO is an American Occupational Therapy Association (AOTA) Approved Provider of professional development (PD). PD activity approval ID# 16104. This Distance Learning-Interactive course is offered at 0.1 CEUs, introductory, OT service delivery, professional issues, foundational knowledge. AOTA does not endorse specific course content, products, or clinical procedures.

    • 1.00 APA

      Continuing Education (CE) credits for psychologists are provided through the co-sponsorship of the American Psychological Association (APA) Office of Continuing Education in Psychology (CEP). The APA CEP Office maintains responsibility for the content of the programs. Participants may earn 1.00 CE credits for completing this activity.

    • 1.00 APTA

      DHA J-7 CEPO is an American Physical Therapy Association (APTA) Approved Provider of continuing education. This activity was planned by and for the health care team, and learners will receive 0.1 APTA CEUs. The assignment of APTA CEUs does not imply endorsement of specific course content, products, or clinical procedures by APTA. APTA CEUs are accepted by most state PT licensing boards. Learners are encouraged to check with their local chapter or state board to ensure that they accept APTA accredited courses for licensure renewal.

    • 1.00 Attendance
    • 1.00 IPCE

      In support of improving patient care, DHA J-7 CEPO is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. This activity was planned by and for the healthcare team, and learners will receive 1.00 Interprofessional Continuing Education (IPCE) credits for learning and change.

    Please login or create an account to take this course.



    Requirements: CE/CME certificates are awarded to participants who fully complete the activity, successfully submit the evaluation survey, and pass the posttest. The deadline to claim credit is May 20, 2026.

    Access Code: Some activities require an access code to register or claim credit. Please contact the organization providing the activity for the access code. The Continuing Education Program Office (CEPO) does not provide access codes.

    Accommodations: Please contact the course instructor to inquire about accommodations. For additional accommodation requests and/or technical support, email [email protected].

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