Two nurses make a medication error: One causes an adverse event with a patient and the other does not. Should the nurses be disciplined, and, if so, should they be disciplined the same way? Why or why not? How would this be addressed in a just culture?
Solution
Just culture is intended to be a learning culture that is constantly improving and oriented towards patient safety. It is related to systems thinking, relating mistakes to the product of faulty organizational cultures rather than the individuals involved, treating those involved in a fair and just manner (Taylor, 2022). In the past, organizations looked to identify “who caused the error” and punish those individuals. However, it was found that this punitive approach often caused fear of reporting and did not solve the problems within the system (Rogers et al., 2019). Punishing people without changing the system only perpetuates the problem rather than solving it” (Boysen, 2013). In a just culture the nurses behaviors should be analyzed to understand what happened, why the errors occurred, and what systems can be put into place to prevent further problems or events. These behaviors are fall into three categories that include human error, at-risk behavior, and reckless behavior. When organizations decide to base their reaction based on the severity of the error, they miss opportunities to address “near misses.” At-risk behaviors are most often the cause for error because of the human tendency to cut corners. When these drifts in behavior become the norm, the responsibility for errors is shared between the nurse and the organization. Once determined cause or intent of actions, human error is treated as consolable and is handled with changes in training, processes and environment. At-risk behaviors are handled in a teachable manner, such as creating incentives for healthy behavior or increasing situational awareness. Finally, reckless behavior is considered punishable. If either error are found to be an intentional violation of process or policy and a conscious disregard to process, then the nurse may receive remedial or punitive action.
Boysen, P. G. (2013). Just Culture: A Foundation for Balanced Accountability and Patient Safety. The Ochsner Journal, 13(3), 400. https://pmc.ncbi.nlm.nih.gov/articles/PMC3776518/
Rogers, E., Griffin, E., Carnie, W., Melucci, J., & Weber, R. J. (2019). A Just Culture Approach to Managing Medication Errors. Hospital Pharmacy, 52(4), 308–315. https://doi.org/10.1310/hpj5204-308
Taylor, L. (2022). Just Culture in Health Care | Balancing Safety and Accountability. Www.justculture.healthcare. https://www.justculture.healthcare/