Website spotlight: Implementing a just culture

Staff Development Weekly: Insight on Evidence-Based Practice in Education, November 21, 2012

First and foremost, it goes without saying that we all want to do the right thing, at the right time, for the right patient the first time, and every time thereafter, without making a mistake or causing harm, ever. And in a perfect world, that's what would always happen-we would take good care of our patients, who in turn would always have great outcomes.

Unfortunately, it's not a perfect world and every healthcare provider will make at least one error during the course of his or her career. Whether it will actually reach a patient is irrelevant. The fact is, an error will still be made, which results in at least one of the following outcomes:

  • Actual event, with patient harm
  • Actual event, with no patient harm
  • Near miss, with no patient harm, but that has the ­potential to cause harm

We also know now that the majority of errors occur from systems failures or process problems, and we know that if we focus on and fix the process, we will have more success in achieving safer patient care conditions than if we target people problems or punish providers for making those errors. It is already well known that how an organization manages its event reporting system tells a lot about the organization's culture. It only follows that an organization with a robust event reporting database in all likelihood has a positive culture of patient safety in which staff members are very comfortable reporting, knowing that there won't be punitive action taken against them. However, we do not discount accountability when an error is made, particularly in light of our understanding of the set of algorithms that help us determine whether the behavior was human error only, at-risk behavior, or reckless behavior. We also know that those who have instituted a culture of patient safety seem to have followed several strategies to ensure successful implementation.

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