However, individual practitioners should not be held accountable for mistakes made in a system they cannot control. In only one of these scenarios does an adverse event occur, yet a just culture, with its insistence on a value-based culture and shared accountability, demands that all of these situations be addressed.
At a later date, the physician confronts the employee who vehemently denies alcohol abuse. The night nurse supervisor reports to a medical director that the lead respiratory therapist was in the hospital at 4:00 am with alcohol on his breath.A surgical team does not perform a surgical time out on the grounds that no adverse events have occurred in the past.Fearing the wrath of the supervising physician, the resident reports that the result is normal. The attending physician tells a resident physician to obtain a specific blood test.How do we approach the nurses and investigate the situation? The other nurse realizes the switch when drawing the solution from the vial into the syringe at the bedside. One nurse administers the drug, causing cardiac arrest. Two nurses select the (same) wrong vial of intravenous medication from the dispensing system.Just culture requires a change in focus from errors and outcomes to system design and management of the behavioral choices of all employees. While the organization has a duty and responsibility to employees (and ultimately to patients), all employees are held responsible for the quality of their choices. 1Ī just culture balances the need for an open and honest reporting environment with the end of a quality learning environment and culture. Finding a balance between the extremes of punishment and blamelessness is the goal of developing a just culture. However, medical institutions cannot afford a blame-free culture: Some errors do warrant disciplinary action. Similarly, people within the organization must believe that they are obligated to report errors. This process is not possible unless members of the organization remain vigilant and mindful and maintain continuous surveillance. Punishing people without changing the system only perpetuates the problem rather than solving it.Ī patient care system is obligated to collect productive investigative data that can be analyzed and acted upon to improve patient safety. An individual may be at fault, but frequently the system is also at fault.
People function within systems designed by an organization. This punitive approach does not solve the problem. One organizational approach has been to seek out errors and identify the responsible individual. In healthcare, errors and accidents result in morbidity and adverse outcomes and sometimes in mortality.
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