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 :
Patients,
Staff,
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.