Patient safety: Facilitating the establishment of a just culture
Briefings on Evidence-Based Staff Development (formerly The Staff Educator), June 1, 2010
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What comes to mind when you think about the term “just culture”?
Consider the following dilemmas:
- Two nurses select the wrong medication from the dispensing system. One dose reaches a patient, causing him to go into shock, and the other is caught at the bedside before causing harm. Do we treat these nurses in the same way?
- A nurse loses custody of a yet unlabeled specimen but chooses not to report the incident out of fear of discipline. Do we forgive the breach, given the nurse’s fear?
- An entire surgical team defends skipping the presurgical timeout on the basis that no adverse event occurred. Do we condone this violation?
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