Nursing 588 Simulation -Just Culture
Objectives:
1. Demonstrate knowledge of just culture
2. Discuss the impact that this error may have on the performance appraisal of the new graduate
3. Utilize root cause analysis to determine what caused the incident including an examination of environmental factors
4. Use principles of performance improvement to analyze the case.
5. Discuss ethical and moral issues related to reporting errors
Content:
Just culture is the notion that when errors occur those responsible for examining them do so with attention to process not blaming the person who is involved. This shift of paradigms from one of a blame culture to a just culture is being embraced across America’s health care industry partly in response to the IOM’s report on errors. Vogelsmeier and Scott-Cawiezell (2007) state that the majority of medical errors are not the fault of people but rather faulty systems, processes, and conditions that lead to medical errors (p. 210). According to schools of thought on performance improvement one cannot change or improve if you do not know where the problem occurs. In a blame culture nurses and other health care providers often under report or do not report errors or near misses for fear of retaliation and disciplinary measures that affect their job. According to Huber (2010) “nurse managers must learn the principles of the non-punitive approach (ie. They applaud and commend staff for reporting errors or “near misses”)(p. 552). In a just culture all health care workers are cognizant of their own work behaviors and strive for safety, quality, and minimization of errors, while at the same time understand that errors should be disclosed.
Just culture in health care is imperative if the quality of care and the safety of patients is to be improved. Within such a culture health care providers feel safe reporting near miss errors or medical errors in an effort to enhance the safety of patients. The focus when errors occur should be on analyzing the situation to determine the root cause of the error. The North Carolina Board of Nursin has developed a tool kit to be used with students in practice events. This too forms the basis of the simulation on “Just culture”. The board identifies four criteria within the practice arena that should be evaluated in terms of the student’s behavior when an error occurs. They are general nursing practice, understanding expected, internal program or agency policies/standards, decision/choice and ethics. Within these criteria the action by the student is classified as human error, at risk behavior, and reckless behavior. In addition, when obtaining a criteria score to determine a course of action, one can consider a set of mitigating factors and aggravating factors. (See Student Practice Event Evaluation Tool).
Resources included:
1. Power point slides from Denise Hirst – “Managing and Improving Quality”, and Larry Mandelkehr “Introduction to Performance Improvement”
2. Khatri, N., Brown, G. and Hicks, L. (2009) From a blame culture to a just culture in health care, Health Care Management Review, 34(4), 312-322.
3. Vogelsmeier, A. and Scott-Cawiezell, J. (2007) A just culture: The role of nursing leadership, Journal of Nursing Care Quality, 22(3), pp. 210-212.
4. Huber, D. (2010) Leadership and Nursing Care Management, (4th ed), Maryland Heights, MO; Saunders Elsevier.