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Ending Kneejerk Responses to Medical Errors

Rebecca Hendren, for HealthLeaders Media, June 21, 2011

"By shared accountability, I mean that the organization is responsible to have good systems that minimize risk," says Raso. "The individual is responsible for their behavior. They are responsible even if they made a mistake."

Raso provides an example. If nurses know the hospital's procedure is to check two patient identifiers before administering medication, then nurses are accountable for doing so. Let's say, however, that an organization uses a flimsy wristband system that is prone to falling off. In addition, there's no way to get another wristband without jumping through five hoops and filling out forms in triplicate. In this case, the organization doesn't have a system to support proper verification of patient ID.

"That's shared accountability," explains Raso. "The staff person is responsible for following safety policies and procedures and for making good judgment. In the end they are responsible for doing the right thing. But the organization is responsible for having systems to support that."

Raso points out that people don't usually break rules intentionally. "So to punish people for breaking rules is not always right because nine times out of 10 everyone is breaking the same rule," she says. "If you have routine violations of a rule, you have to make it part of investigation and have a systemwide corrective action plan. It's usually about systems, not people"

In a Just Culture, organizations perform a thorough investigation following an incident or a near miss, similar to a root cause analysis. It's important that staff are educated about the process or they may fear the investigation is looking for a scapegoat.

"Make it very clear that it's not a witch hunt," says Raso. "Say, this is not about punishing you. We are here to learn what happens so we can fix systems that support you to give best care possible to our patients.'"

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