Just Culture is the approach of addressing issues in a work environment that can lead to staff members engaging in unsafe behaviors. At the same time, the unit attempts to maintain individual accountability. This is done by establishing a zero tolerance for reckless behavior, but understanding that human error and at-risk behaviors can cause errors. Reckless behavior is when an individual knowingly disregards hospital policies and procedures placing patients directly at risk. These behaviors are placed as zero-tolerance and administrative action may be taken (AHRQ, 2016). Human errors occur when healthcare providers accidentally perform something that is wrong or unsafe. At-risk behaviors are actions taken by providers that increase the odds of a mistake or the overall risk from treatment. For an action to be an at-risk behavior and not reckless behavior, it must be either not recognized as wrong or believed to be justified. In a Just Culture, the reason for error must be identified and addressed properly to ensure that staff members feel supported by their leadership and safe practices can be optimized. Systems that increase the likelihood of human errors or at-risk behaviors are identified and modified to decrease their possibility. Staff members that perform reckless behavior are identified, corrected and if needed disciplined (Ulrich, 2017, p. 207).
A Just Culture is more focused on fixing the problem than disciplining staff members. Prior to the implementation of this type of philosophy, staff members would cover up or lie about adverse medical events because of the risk of punitive action. This made it hard for facilities to gather information and fix problem areas in their policies and procedures. Creating an environment where the staff feels supported by their leadership, focused on finding solutions, not leary of punishment and driven for safe patient care has increased reporting of adverse medical events. This has led facilities to identify what their unit weaknesses are and address them with more complete information (Ulrich, 2017, p. 207). Nursing intervention: Leadership is needed to make sure that Just Culture is present in a facility. Just Culture begins with the leadership outlook and is integrated with interactions between leaders and their subordinates. Leaders must communicate actions that are standards for the unit through their policies and procedures. Nurses make an environment that facilitates Just Culture by placing the safety of the staff and patients first. This leads to team members responding to errors in a way that identifies facts and improve systems. Leaders reduce the importance of placing blame which creates an open line of communication between team members (Ulrich, 2017, p. 207).
Practice example: A nurse places multiple patients’ identifying labels in their scrubs prior to obtaining a urine sample from their patient. Once the patient produced a clean catch sample the nurse obtains a specimen label from their scrubs and attaches it to the collection container. The practice of the nurse leads there to be multiple patient labels from different patients in their pocket at one time. The nurse labels the specimen incorrectly with the wrong patient identifier. When the results are returned, they are for the wrong patient and the nurse identifies the reasoning for the mistake. The nurse ensures to collect another specimen and label it with the correct label the second time. The unit is compliant with the Just Culture philosophy. The nurse knowing this reports the error to their supervisor for correction. This error may fit as a human error that was created by a break in the system and laziness by the nurse. The unit management identifies the break in the system and implements two solutions for the error. The unit puts out a policy that nurses cannot carry patient labels on them unless going to the patient’s room. Labels are not to be stored on a nurse’s person through their shift. The unit also creates a procedural change that forces the staff to scan the patient’s wristband and sample label prior to sending it to the lab.
Near Miss Event Description: A ‘near miss event’ is an error that has the potential to cause harm to a patient, but fails to do so due to sheer luck or because of an interceptive action. Inpatient care settings many of the near-miss events are medication related. Medication administration is relatively complicated which leaves many opportunities for errors to be made such as a provider failing to consider a patient’s allergies, failure to consider side effects of a medication and significant drug interactions. (Sheikhtaheri, 2014) Other examples of near-miss events include incomplete or accidental patient falls, mislabeling specimens, or even preparing an incorrect area prior to surgery. Near-miss events are important as they show evidence of error-prone areas or conditions. Many patient safety experts have determined that many of the root causes of near misses and adverse events are quite similar. By detecting the root causes of these events, providers can correct these causes and hopefully prevent future near miss events further reducing risks for patients and staff. These close calls actually have a unique advantage and that is because no damage actually occurs. Those reporting of or participants in a near miss event do not face any legal liability or disciplinary action. (Sheikhtaheri, 2014)
Therefore, individuals are encouraged to report these events to help create quality improvement reform. Nursing Interventions: Implementation of an online reporting system would benefit the organization and staff by easing the burden of reporting near-miss events. Online reporting facilitates analysis of the data; analyzing the event data can provide helpful information about the nature of the event and frequency and safety issues surrounding the incident. Because close calls happen as many as 300 times more than actual adverse events, it is recognized that there are more systemic flaws compared to isolated individual errors (Wu & Marks, 2013). This creates the need for systemic reform regarding patient safety and changes to those specific policies and procedures. After analysis, implementation of specific provider related interventions should be created such as one to one observed patient ambulation with a gait belt and controlled fall for those at fall risk or a ‘4-eye’ check prior to administration of a critical medication such as insulin.
Practice Examples: Prior to surgery, an anesthesiologist thought he was holding a vial of 0.9% sodium chloride. Instead, he was holding a vial of succinylcholine, a neuromuscular blocker used as a paralytic prior to surgery, the provider realized this potentially lethal mix-up. Because no harm occurred, a ‘near miss’ report was submitted, detailing the close call. The hospital system developed and implemented a red warning label on these medications to help prevent similar events from occurring. A 75-year-old man is awaiting knee replacement surgery on his right knee. Prior to entering the surgical suite the orthopedic surgeon is reviewing the patient EHR and recalls the right knee was to be operated on. Upon entering the OR, the surgeon realizes that the patient’s left knee had been marked with a skin marker, cleansed and a sterile field had been prepared. He then clarifies the patient identification and correct surgical procedure. A ‘near miss’ report was submitted and the department leadership was notified. Development and implementation of a dual identification protocol is now in use. Now the surgeon, anesthesia provider and OR nurse must verify the patient and procedure prior to sedation and preparation. Never Event Description: A “never-event” is an untolerated clinical error expected to be entirely prevented by implementing adequate safety measures and following practice protocols (Zamir, Beresova-Creese, & Miln. 2012).
Never events can occur during complicated cases because of clinician/nurse inexperience, but more commonly they occur from simple human error. While human error cannot be eliminated, it can be lessened with routine safety protocols such as checklists, wristbands, and EHR reminders. (Zamir, Beresova-Creese, & Miln. 2012) Never events, unlike near-miss events, are actually followed through with, and the patient and provider have to manage the consequences of the mistake. Nursing Interventions: Never events are expected to be avoided by diligent nursing practice and common sense. Many of the policies and procedures that we are taught in school have been put into place by sentinel events that are now expected to never happen. Aside from the severe risk to the patient, when never events happen the hospital must pay out of pocket to cover the cost of caring for the patient and they “are publicly reported, with the goal of increasing accountability and improving the quality of care” (Haas, 2012).
Some policies that have been implemented include: scanning patients’ wristbands and medications before administration (10 rights of medication), triple checking surgery sites, always implementing fall precautions, doing thorough inspections of skin integrity upon admission to the hospital and documenting all findings, turning patients every two hours who are unable to do so on their own to prevent pressure ulcers, 24 hour watch for suicidal patients, and strict rules regulating the use of restraints on patients. Nurse leaders should be at the forefront of developing these evidence-based practices in their facilities if there is nothing already in place. This not only protects the facility itself, but also sets the employees up for success and their patients for continued safety while receiving care. Practice Examples: There are a few common examples of never events: wrong amputation/organ removal, wrong blood-type transfusion, hospital-acquired pressure ulcers, and leaving surgical foreign bodies in the patient (Zamir, Beresova-Creese, & Miln. 2012). These largely preventable mistakes are life-altering for the patient, and they may cause permanent damage to the patient’s physiological and psychological health. A malpractice case against the medical institution that allowed the error to occur is also likely to happen; 82% of malpractice claims are correlated with system errors (Zamir, Beresova-Creese, & Miln. 2012).
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