Welcome back everyone.
In healthcare, sometimes errors occur.
If you work in an environment which punishes those who make
unintentional mistakes without getting to the root of the problem,
employees may not feel comfortable
dissclosing them if the event occurred,
which of course may lead to additional
errors putting patients at risk.
Organizations who understand this potential
hazard strive to adapt a just culture.
A just culture balances the need for an
open and honest reporting environent
with the end of a quality learning
environment and culture.
In a just culture, accountability and quality are achieved
by improving processes and systems in the work environment.
The goal of a just culture is the development of an
organizational culture that promotes and exhibits
a quality learning environment as a
responsibility to both employees and patients.
Every employee is held accountable for patient safety
and the quality of his and her practice choices
In a just culture, the focus is on systems
design rather than blame for errors.
There are some requirements.
It requires a creation of an open,
fair and learning environment
The design of safe systems.
Management of behavioral choices
To create a just culture, all organization
layers must be engaged in open communication,
and willing to shed any preconceived
notions of error reporting.
For many organizations, the largest
barrier is the establishment of trust
which is vital in the reporting of
errors and the analysis of processes.
One of the first steps in establishing trust is
setting organizational rules and practice standards
that are applicable to all layers of the organization based on
mutual values and a communicated, enforced mission statement.
Every member of the organization needs to
know the strategic plan and what's expected.
The key is to manage these
expectations along with behaviors
Now there are three categories of behavior:
Human error, at risk behaviors
and reckless behaviors.
Now many times, human errors are attributed
to poor processes, or poor programs,
poor education or poor environmental
issues or situations.
These errors are managed by correcting the cause looking
at the process and fixing the deviation - not the human.
At risk behaviors - these occur when
it's easier to make the wrong choice.
For example, working around the medication administration policy by
pulling the medication under another patient's name in an emergency.
Or failing to scan the medication when the scanner won't accept
the patient's band but delivering the medications anyway.
The way to address this once identified is
to make the correct choice more rewarding.
For example, by recognizing scanning compliance.
or setting up medication dispensing systems with
medications that can be placed in "override"
in an emergency situation so that
the correct patient is identified.
For recekless behaviors, this is
addressed by correcting the person.
Reckless behavior by choice is when the nurse intentionally
disregards medication administration policies
and deliberately foregoes
the safety mechanisms.
This can be addressed by progressive discipline that
begins with reeducational policies, procedures
and why they're in place.
Continued failure to follow policies and
procedures places the follwoing at risk :
and the whole organization.
So let's consider this example.
Two nurses select the same wrong vial of
intravenous medication from the dispensing system,
one nurse administers the drug,
causing a cardiac arrest.
The other nurse realizes the switch when drawing the
solution from the vial into the syring at the bedside.
Further investigatoin showed that the two vials of entirely
different medications looked alike in shape, size, color and print.
So which category of behavior
is demonstrated in this error?
Human error, at-risk behavior or reckless behavior?
The correct answer is human error.
When the nurse took the wrong medication, she wasn't doing
it intentionally nor was she trying to circumvent the system
because both medications looked so
similar, it was an innocent mistake.
So remember, a just culture in which
employees aren't afraid to report errors
is a highly succesful way to manage safety, increase
staff and patient satisfaction, and improve outcomes.
So in thinking of everything we've covered
today, I'd like you to consider this question:
What is the primary focus of a just culture?
It's focus is on systems design
rather than blame for errors
So hope you've enjoyed today's
video on just culture
Thanks so much for watching.