In a just culture, the approach to addressing medication errors focuses on fairness, learning, and system improvement rather than punitive measures, unless there is evidence of reckless behavior or intentional harm. The American Nurses Association (ANA) supports this framework, recognizing that errors often stem from system failures or human factors rather than individual negligence alone (Woo & Avery, 2024). In the case of two nurses making a medication error, where one results in an adverse event and the other does not, the response should be guided by the principles of a just culture. If the error was due to system issues, such as unclear protocols, fatigue, or distractions, discipline is not the primary focus. Instead, the organization should investigate the root cause, address systemic flaws, and provide support and education to both nurses to prevent future occurrences. However, suppose one nurse demonstrated reckless behavior or intentionally disregarded safety protocols. In that case, disciplinary action may be warranted for that individual, while the other nurse, who did not exhibit such behavior, should not be disciplined similarly. The key is to ensure accountability is proportional to the actions and context of the error, emphasizing learning and improvement over punishment. By fostering a just culture, organizations can create an environment where nurses feel safe to report mistakes, contributing to safer patient care and continuous system enhancement (Albeshri et al., 2024).

References:

Albeshri, S. M., Alharbi, R. A., Alhawsa, H. Z., Bilal, A. M., Alowaydhi, B. Y., Alzahrani, O. M., Fallata, S. M., Almaliki, S. O., Alfadly, W. N., & Albarakati, A. O. (2024). The role of nursing in reducing medical errors: Best practices and systemic solutions. Journal of Ecohumanism, 3(7). https://doi.org/10.62754/joe.v3i7.4574

Woo, M. W. J., & Avery, M. J. (2024). Supporting nurses’ commitment towards voluntary error reporting: A discursive paper of current policies and recommendations. Asia Pacific Journal of Health Management, 19(3), 1–10. https://doi.org/10.24083/apjhm.v19i3.4157