Adverse events in healthcare are not very common, but they are taken very seriously. Medication errors are perhaps the most notable types of adverse events. While these errors can negatively impact patient safety, trust, and satisfaction, they also provide valuable learning opportunities.

Disciplinary actions are reinforced to promote accountability. However, before determining the appropriate disciplinary measures, it is important to conduct a root cause analysis. Every healthcare organization should have the capability to carry out an assessment involving a risk management team and an ethics committee. Identifying all contributing factors such as unclear directions, availability of medication, time constraints, improper equipment, human error/carelessness, etc are all essential considerations of this medication error.

Both scenarios provide opportunities to identify areas for improvement and implement preventive measures to avoid future occurrences. When it comes to disciplinary actions, after a thorough investigation of each isolated incident, it’s crucial to apply a just culture algorithm to determine the appropriate action. In an organization that values a culture of excellence and patient safety, fostering open communication and viewing mistakes as learning opportunities is the best strategy for maintaining a comfortable and inclusive environment. Utilizing just culture in scenarios such as medication errors are ways to reiterate how mistakes will happen but also increases the morale of the teams so that trust can be built. According to the JustCulture toolkit, professionals and those operating the system can learn without fear of retribution when something goes wrong.

Just Culture Toolkit. (n.d.). https://www.ashp.org/-/media/assets/pharmacy-practice/resource-centers/patient-safety/Just-Culture-Toolkit_-Final.pdf

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