Website spotlight: Ending kneejerk responses to medical errors
Nurse Leader Weekly, June 27, 2011
Want to receive articles like this one in your inbox? Subscribe to Nurse Leader Weekly!
Mistakes are a fact of life. As the Institute of Medicine said, "To err is human." What matters is how we respond to mistakes, which involves putting systems in place to stop errors before they happen and supporting clinicians who make mistakes.
Not long ago, the catch phrase was "no blame" culture, where people talked about non-punitive responses to patient safety incidents. But simply saying "no blame" doesn't take the complexities of medical errors into account. Removing personal accountability from individuals isn't the answer, but neither is a rush to judgment and punishment that we know still occurs too often.
A balanced response that emphasizes individual and organizational accountability is Just Culture, a concept originating in aviation and crew resource management and lately honed by engineer David Marx. The Just Culture process involves purposeful responses to situations that investigate exactly what went wrong and why so as to understand everything, without falling prey to kneejerk emotional reactions that attribute blame.
One organization that has been working on establishing a Just Culture for the last few years is Lutheran Medical Center in Brooklyn. Rosanne Raso, RN, senior vice president, nursing services, says the most important concept of a Just Culture is to remove the emotional response that occurs whenever there is a medical error or a near miss.
"The old way of doing things was to have a kneejerk reaction and punish people and that doesn't fix anything," says Raso. "You have to investigate and look into why things happened. You can't make any decision or judgment about what happened until you really dig into the whys. You don't know how to fix it until you know what went wrong."
Editor's note: Read the rest of this free article in the Reading Room at www.StrategiesForNurseManagers.com.
Want to receive articles like this one in your inbox? Subscribe to Nurse Leader Weekly!
Related Products
-
Strengthening Nurse-to-Nurse Relationships:
This educational video will help nurses at all levels understand the issue of horizontal hostility. It provides the expert...
-
Core Skills for Nurse Managers
Turn to this ready-to-use and effective training program to equip new nurse managers--and experienced nurse managers who may...
-
Ending Nurse-to-Nurse Hostility:
Through captivating anecdotal scenarios, author Kathleen Bartholomew, RN, MN examines the many facets of horizontal...
-
Nursing Orientation Program Builder:
This binder and CD-ROM walk you through each step of a well-run orientation program so you can incorporate field-tested...
-
Lead! Becoming an Effective Coach and Mentor to Your Nursing Staff
This management resource for nurse leaders is packed with communication strategies and proven methods to help elevate the...
Most Popular
- Articles
-
- Featured blog post: Nurses face felony charges after reporting physician to the Texas Medical Board
- Topic: CMS, OESS post new security compliance review information, checklist
- Q/A: Volume requirement for reporting hydration services
- HIPAA Q&A: Answering service messages
- News and briefs: Oklahoma Osteopathic Association against residency bill change
- What does case-mix index mean to you?
- QA:Coding multiple initial infusions
- OB services: Coding inside and outside of the package
- State medical board will hear unprofessional charges against OB-GYN
- The debate continues: Nurses who reported physician to the Texas Medical Board file federal appeal
- E-mailed
-
- Featured blog post: Nurses face felony charges after reporting physician to the Texas Medical Board
- Are your workforce members texting PHI?
- Don't let these sentinel events trigger falsely
- Arkansas woman convicted for HIPAA violation
- Q/A: Coding infusions to correct low potassium levels
- Q&A: Coding for protein malnutrition
- Q&A tackles coding questions about injections and infusions
- Joint Commission Center announces handoff communication solutions
- Inside best practice: Reduce patient falls with a stoplight
- Identify modifiable risk factors to prevent patient falls
- Searched