In his testimony before Congress, Dr. Lucian Leape Professor at Harvard School of Public Health stated, “The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes.” A just culture takes the focus off errors and outcomes and places it on the quality of system design and behavioral choices. Just and accountable cultures view unanticipated outcomes and events as opportunities to inform their risk model by designing and implementing systematic and uniform processes designed to support practice. The benefit Just Culture brings to an organization includes timely identification of adverse issues with development of a course of action for immediate remediation.