The implementation of a 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. 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 then 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 weary of punishment and driven for safe patient care has increased reporting of adverse medical events. This has led facilities to identify what their unit weakness are and address them with more complete information (Ulrich, 2017, p. 207).
127 our experts are availableright now
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.
