NURS 8302 Just Culture

NURS 8302 Just Culture

NURS 8302 Just Culture

Making mistakes is human. In healthcare, a lot of the mistakes being made are preventable if the human  was using the right kind of system—one that makes it more likely that the right choice will be made versus using work arounds because it’s too difficult to accomplish the goal using the system as designed (Kohn, Corrigan, & Donaldson, 2000). Healthcare facilities need to put systems in place that are efficient and make it easy to do the right thing. In order to accomplish this, they must be aware of the details of mistakes so the system can be changed to mitigate the error. In order for leadership to become aware of the mistakes, the mistakes must be reported. In order for workers to report mistakes, they must feel safe doing so. This is a Just Culture (Barkell & Snyder, 2020).

My Organization’s Safety Culture

When I was a patient safety manager 10 years ago, my facility did not have a Just Culture. This made my job as patient safety manager very difficult. In fact, it was the reason I left that facility. I tried hard to inform leadership about the role of a patient safety manager as I had been trained. However, it was clear that they did not understand that I was manager of the patient safety program and not of people. I was to be unbiased, neutral, and nonpunitive in my role. I informed them that I was not to be used to punish anyone, nor the incident reports that I received were to be used for the same. I also tried to convince the workers to report incidences. However, to no avail, leadership continued to focus on why the individual didn’t follow the rules and workers rarely report incidents and confidentially told me they were concerned about retaliation. Every year for the three years I worked there, less than 20% of the employees even took the annual safety culture survey despite my month-long campaigns to encourage participation.

DNP-prepared Nurse’s Role in Supporting a Just Culture Environment

DNP Essential II focuses on organizational and systems leadership for quality improvement and systems thinking.

NURS 8302 Just Culture
NURS 8302 Just Culture

This means that as a DNP-prepared nurse, I must develop care delivery models from the view of an entire system, not just from the individual level. I must do this keeping in mind the perspectives of the culture involved (American Association of Colleges of Nursing, 2006). I imagine that as a DNP-prepared nurse today at that facility, first I would measure the safety culture using the Agency for Healthcare Research and Quality’s (AHRQ) Patient Safety Culture Surveys and the Safety Attitudes Questionnaire. Once I get a good idea on the culture, I would follow AHRQ’s guidelines for achieving a culture of safety in incremental changes (PSNet, 2019).

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References

American Association of Colleges of Nursing. (2006, October). The Essentials of Doctoral Education for Advanced Nursing Practic. Advancing Higher Education in Nursing. Washington, DC: DNP Essentials Task Force. Retrieved from www.aacn.nche.edu

Barkell, N. P., & Snyder, S. S. (2020). Just curture in healthcare: An integrative review. Nursing Forum, 103-111. doi:https://doi.org/10.1111/nuf.12525

Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (2000). To err is human: Building a safer health system. Washington: National Academy Press.

PSNet. (2019). Culture of safety. Retrieved from Agency for Healthcare Research and Quality: https://psnet.ahrq.gov/primer/culture-safety

According to Eng and Schweikart (2020), just culture is a trusting environment in which healthcare personnel is supported and treated fairly when something goes wrong with patient care. Consider the situation in which a nurse discovers that a colleague will give a patient the incorrect medicine dose. She realizes that the drug has been administered before she gets to the patient’s room. She calls the coworker outside to speak with him and informs him that the dosage is incorrect. They debated it and agreed that if medication to prevent an overdose reaction is not given, the patient will most likely face serious side effects. Despite their fear, they gather the courage to inform the in-charge doctor.

The doctor acts promptly and finds a way to stabilize the patient’s health before any catastrophic effects arise. The nurses are then brought to a meeting to discuss how to avoid such incidents in the future and the steps to follow. They are also reminded of the numerous drugs administered in the hospital. The management decides to implement a training matrix that requires employees to attend seminars and workshops to refresh and improve their healthcare knowledge. Employees are encouraged to report any medication delivery errors that could put a patient at risk.

Consider the case where a nurse picks the wrong drug from the dispensing system and gives it to a patient. The patient is in a condition of shock because of the medicine. The nurse is perplexed when she realizes her mistake. She is afraid of losing her work if she reports the incident. The patient dies, and the truth is only found after a postmortem. Even though the nurse is summoned and accepts responsibility for her error, she is fired. Openness, universal and reciprocal accountability, patient-centered care rather than doctor-centered care, perceiving errors as system failures rather than individual faults, and encouraging teamwork are all features of a just culture (Eng & Schweikart, 2020).

In the first scenario, the nurses are entirely transparent. Their decision to tell the truth resulted in saving a life and the improvement of the hospital’s standards. The nurse’s choice in the second case resulted in the death of a patient. He lost his job. If he had followed the correct procedures, she could have saved a life, other people would be motivated to speak up if they made a mistake, and the hospital would have learned from the error and made changes as a result.

Reference

Eng, D., & Schweikart, S. J. (2020). Why accountability sharing in health care organizational cultures means patients are probably safer. AMA J Ethics, 22(9), E779-783. Doi: 10.1001/amajethics.2020.779.