The focus in a just culture is on uncovering what caused the errors and making system improvements in order to prevent recurrences while also holding people accountable. Creating better work systems requires a just culture that supports accountability between employees and organizations (Taylor, 2022). Discipline is not always needed, as it depends on the circumstances under which the medication error occurred. Emphasis is placed on improving systems rather than punishing employees. Ideally, we want individuals to report errors, learn from them, and remain accountable. Disciplining individuals without taking care of the cause only worsens the problem instead of resolving it (Murray, 2023).

Two nurses made a medication error. First, it is to determine what caused the error to happen. Although it is unfortunate that an adverse event took place, was it the result of negligent or careless actions on the nurses’ part? Did the nurses fail to follow medication rights or bypass scanning? Or were there system or organizational failures? Did they show remorse towards the patients involved? Understanding what caused the error can be used to determine if discipline is necessary. If the error resulted from a flawed system, then improving the system is more appropriate than disciplining the nurses. If the nurses failed to follow policy or acted recklessly, then discipline would be appropriate.

References

Murray, J. S., Lee, J., Larson, S., Range, A., Scott, D., & Clifford, J. (2023). Requirements for implementing a ‘just culture’ within healthcare organizations: an integrative review. BMJ Open Quality, 12(2), e002237. https://doi.org/10.1136/bmjoq-2022-002237

Taylor, L. (2022). Just Culture in Health Care | Balancing Safety and Accountability. www.justculture.healthcare. https://www.justculture.healthcare/