Ask the expert: Encouraging a Just Culture for reporting errors and near misses

Nurse Leader Insider, June 27, 2011

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This week, Vivian B. Miller, BA, CPHQ, LHRM, CPHRM, FASHRM, discusses how managers can get started with adopting a Just Culture.

Q: How does my organization establish a Just Culture that encourages nurses to report errors and near misses so we can learn from our mistakes?

A: It is important for hospitals and staff members to be continuously reminded that the primary, strategic focus for any healthcare entity should be patient-centered care that keeps patients safe. Patient-centered care should include a mechanism whereby hospital personnel and/or the medical staff are comfortable reporting any medical error through the appropriate channels in a continuous effort to improve the quality of care provided. It is also imperative that staff members be involved in the initiative for organizational cultural change, because if the staff isn't on board with the concept-even if the board and senior leadership are-the initiative will fail.

Now that the need for change is recognized, it is time to get started. This is an exciting journey, although at times it can be quite challenging. Still, staff want to do the right things for their patients; they want to provide the right care to the right patient at the right time and in the right setting. The overall goal of a Just Culture is to look beyond the individual when an error occurs. Making the individual aware of outcomes and holding the individual responsible for learning from his or her mistakes and to perform according to pre-set expectations in the future, while at the same time evaluating the processes leading up to the error, identifying breaks in those processes, and correcting them, the organization demonstrates its commitment to objectively understanding why the error occurred and adopting a systematic approach for addressing them without staff fearing there will be adverse consequences to them, personally or professionally.

Click here to read the action plan for getting started.

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