Just Culture In Nursing Practices: A Case Study

Beginning of the call the customer asked to speak to a supervisor due to extreme aggravation and disappointment with customer service. Since previous CAEs had provided false information regarding her technician appointment. Since customer is upset, she demands for a technician appointment for that same day and wants a credit applied to her account for entire month of service. The customer was very specific that she does not want a prorated credit for the lost internet service but for a total worth of 1 month for all her services.

Errors occur in health care as well as every other very complex system that involves human beings. The message in “To Err is Human”, by Archie Cochrane, was that preventing death and injury from medical errors requires dramatic, system wide changes. Health care professionals have customarily viewed errors as a sign of an individual’s incompetence or recklessness. As a result, rather than learning from such events and using information to improve safety and prevent new events, health care professionals have had difficulty admitting or even discussing adverse events often because they fear professional censure, administrative blame, lawsuits, or personal feelings of shame.

One of the most critical factors which contribute to the number of preventable cases of healthcare harm is the culture of silence surrounding these cases. The fear of medical providers to report incidences is related to the possibility of punishment and liability due to a medical error (Discovery, 2010). The criminalization of some acts of medical error has resulted in job dismissal, criminal charges and jail time for some healthcare workers. This is despite the fact that the system they are working in helped to create the situation which led to the error in the first place. Human error, due to fatigue and system errors can result in deadly consequences, but by criminalizing the error it effectively shuts down the ability to correct the root problem. Healthcare workers, working at all levels within the medical system, can provide valuable input on how to improve the processes and prevent harm from occurring (Discovery, 2010).

A medical error can be defined as a preventable and adverse effect of care and one that changes the lives of all those involved-whether it be the patient, the nurse, or the physician (Grober & Bohnen, 2015). Prior to reading The Wall of Silence by Gibson and Singh (2003), I was unaware of not only how common medical errors in healthcare are, but also how they affect people from all walks of life. Medical errors do not only occur in underserved regions with understaffed medical facilities, but they can also occur in what many consider the “best” areas with fully staffed and fully equipped hospitals and medical centers. Before reading this text, it was my belief that errors in healthcare occurred rarely and at best, effected one patient per every

In healthcare systems, there is a concept of fair and just culture. That concept is important to manage the risk. In any organization, errors can happen. But, the best first tool to understand the error is to report it when it happens. Reporting error in healthcare contributes to minimize the risk of recurring.

The third leading cause of death in America may surprise you. Hospitals and healthcare organizations dedicate their branding to reflect a place of hope, comfort, and healing when ones health is compromised. Sadly, medical errors do exists in the realm of healthcare. The National Center for Biotechnology Information defines medical error as “an act of omission or commission in planning or execution that contributes to or could contribute to an unintended result.” Medical errors may include incorrect record keeping, administering incorrect medication to a patient, misdiagnosis, failing to remove all surgical instruments and performing surgery on the incorrect site. The Agency for Healthcare Research and Quality identified eight factors that contribute to the cause of medical errors. These factors include “communication problems, inadequate information flow, human problems, patient-related issues, organizational transfer of knowledge, staffing patterns, technical failures and inadequate policies and procedures.”

There are two common ways to handle a medical error. One is by blaming the individual or things when the error occurs, called it the “culture of blame”. The other one is by focusing on the safety goal using effective systems and teamwork, called “culture of safety". We may say that one is more applicable than the other, or maybe one is more beneficial than the other. In real life though, only one can be applied in a healthcare system, the one that is proven effective regardless its origin, pragmatic, or .

New innovations are being created every year to help improve and protect patients from reckless and preventable errors. As healthcare providers, it is our duty to provide care ethically and to do no harm to our patients. On the contrary, “the culture of cover-up” still continues to exist today and although technology and informatics has progressively increased quality care, it has not completely eradicated errors. Integrity is the key component for every healthcare provider, along with other characteristics. Therefore, disclosing medical errors with our patients is imperative and our patients and their families deserve to know what occurred during their time of care. Technology is not able to prevent every mishap that causes patients harm (Gibson & Singh, 2003). On the other hand, communication and learning from the mistake can. As Gibson and Singh (2003) so eloquently stated, “…wise people learn form their mistakes, and those who don’t are bound to repeat

The Health Care Industry is complex and is responsible for the health of the country (The Hospital & Healthsystem Association of Pennsylvania; Outcome Engineering, 2010), and ultimately of the world. Unfortunately, according to the Institute of Medicine's comprehensive report, "To Err Is Human," avoidable medical errors annually kill 44,000 - 98,000 hospital patients (Reiling, Knutzen, & Stoecklein, 2003). In addition, as of March 31, 2010, the ten most frequently reported sentinel events within U.S. healthcare organizations are: "wrong site surgery; suicide; operative/post-operative complication; delay in treatment; medical error; patient fall; unintended retention of a foreign body; assault, rape or homicide; perinatal death or loss of function; patient death or injury in restraints" (HealthLeaders Media, 2010). Clearly, many of these

According to the Institute of Medicine, “the biggest challenge to moving towards a safer health system is changing the culture from one of blaming individuals for errors to one in which errors are treated not

The human factor approach of Reason defines errors according to two types of failure: active and latent failure, with adverse events at times involving a combination of the two. Active failures are defines as “unsafe acts (i.e. errors and violations) committed by those at the human system interface”.20-22 Active errors occur at the level of the operator, and their effects are felt almost immediately. This is sometimes called the sharp end.20-22 Staff actions at the (sharp end) of patient care may involve slips (e.g. picking up the wrong syringe), cognitive failure (e.g. memory lapses or misreading of information), and violation (deviation from standard procedures or processes). Latent failures stem from decisions, essentially made by management and more senior clinicians within the healthcare setting, which provide conditions in which unsafe acts occur (e.g. inadequate system of communication; poor rostering of staff; inadequate supervision; understaffing) and also weakness in defenses (e.g.

The IOM’s report “To Err is Human: Building a Safer Health System” shocked the health care world and made change necessary. “To Err is Human: Building a Safer Health System” released information that reported that tens of thousands of Americans were dying each year from errors (IOM, 1999). Patient safety moved to the forefront in healthcare like never before and directives were discussed to put quality as a

There are 440,000 people a year that die from a preventable variety of mistakes that are made in hospitals, which comes out to a little over 1,000 deaths a day, and is the number three cause of death behind cancer, and heart disease (hospitalsafetyscore). According to a group that rates hospitals named The Leapfrog Group a nonprofit watchdog group that grades hospitals for safety, (leapfrog) a majority of these deaths are very avoidable and are most of the time simple mistakes. Errors in Hospitals are a broad issue that gets hundreds of thousands of people killed every year; for the most part, they are preventable and are caused by overtesting, overdiagnosis, overtreatment, non-reporting, and lack of oversight, though there are ways to prevent

It is shocking to know that every year 98000 patients die from medical errors that can be prevented(Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.), 2000). Medical errors are not a new issue in our healthcare system; these have been around for a long time. Hospitals have been trying to improve quality care and patients safety by implementing different strategies to prevent and reduce medical errors for past thirty years. Medical errors are the third leading cause of death after heart disease and cancer in America (Allen, 2013). In addition medical errors are costing our healthcare system an estimated $735 billion to $980 billion (Andel, Davidow, Hollander, & Moreno, 2012).

Keeping patients safe is essential in today’s health care system, but patient safety events that violate that safety are increasing each year. It was only recently, that the focus on patient safety was reinforced by a report prepared by Institute of medicine (IOM) entitled ” To err is human, building a safer health system”(Wakefield & Iliffe,2002).This report found that approx-imately 44,000 to 98,000 deaths occur each year due to medical errors and that the majority was preventable. Deaths due to medical errors exceed deaths due to many other causes such as like HIV infections, breast cancer and even traffic accidents (Wakefield & Iliffe, 2002). After this IOM reports, President Clinton established quality interagency