1. Kennedy, Bryan MS, RN, NEA-BC

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In his first week of orientation, a young nurse miscalculates the dosage of a sedation infusion and delivers 100 times the prescribed amount. Another nurse, a single mother of three children, hasn't slept in 2 days but shows dedication by working her third night shift in a row. Due to fatigue, she makes the same miscalculation and administers an excessive dosage. Yet another nurse, known to peers as the self-proclaimed "angel of death," is caught running a similar lethal dosage in an attempt to provide her version of comfort care despite a recent warning that this behavior is intolerable. The new nurse's patient dies, whereas the others survive. What's the proper manager response for each incident? (See Table 1.)

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Table 1: Responding ... - Click to enlarge in new windowTable 1: Responding to errors

That answer may be made easier by following the principles of just culture, a thought process designed by engineer and attorney David Marx. The just culture philosophy was initially used in the aviation and space exploration industries, but has also proven to be useful in the healthcare industry.1 Marx describes the application of just culture to healthcare by explaining that revoked licenses, criminal prosecutions, and unprecedented fines may not be appropriate responses to normal human limitations.2


A step in the right direction

In 2010, the American Nurses Association (ANA) published a position statement supporting just culture principles. The organization endorsed the value of reporting errors and revisiting processes that leave workers open to risk. The ANA recognized the benefits of applying nurses' critical-thinking skills to solving care delivery problems in the same way they approach patient problems. The ANA's position was soon supported by the American Organization of Nurse Executives and the Association of periOperative Registered Nurses.3 Industries that operate in hazardous environments, such as nuclear energy or aviation, have demonstrated remarkable advances in safety, thus earning the title of high-reliability organizations. The just culture model is one component of these industries' safety initiatives. Research is emerging on the use of these safety measures, particularly just culture, to bring the same advances to healthcare.4,5


Error reporting in healthcare is often hampered by two concerns: 1) fear that consequences or blame will fall on the reporter and 2) doubt that improvements will be made based on lessons learned from the report. However, recognition and staff reporting of errors are critical components in the effort to make hospitals safer.6 Understanding fear and doubt enables nurse managers to play a key role in promoting a culture that allows mistakes to be a learning experience for everyone while requiring accountability to professional care standards. To overcome these fears, a cultural shift must occur within the organization.


An organization progresses toward a just culture by honing five skills:


1. adhering to values that support the organization's mission and vision


2. creating systems and processes that anticipate human behavior and incorporate steps to prevent errors


3. empowering employees to make correct choices and learn from their mistakes while using counseling and punitive measures appropriately to shape undesirable behaviors


4. ensuring mistakes are always reported, regardless of whether harm reached the patient, to promote a continuous improvement model that's understood by all staff members


5. making a commitment to differentiating mistakes from disregard of normal procedures and holding staff members accountable when they've intentionally performed outside of accepted protocol.



These skills aren't easily implemented and they take time to become interwoven into a system's culture. Over time, employee honesty and appropriate leadership responses will create change to drive improvements and promote a safer environment.7


Investigating errors

A manager's response to an adverse event in a just culture environment is governed by principles that aim to understand the root cause of the event. The initial response is to simply ask what happened and allow the employee to discuss his or her perspective of the incident. Following this explanation, identify the normal procedure that both the employee and his or her peers followed. Consider the process involved and whether the system facilitates or deters the error. Next, determine the cause and the explanation behind any errors that were made. Finally, consider how the organization has been responding to similar events, keeping in mind the mantra, "What we don't condemn, we condone."


Considerations during an investigation include avoiding early assumptions of cause and jumping to conclusions. Seek input from everyone involved or those who are skilled and familiar with the normal process in question. If you've encountered the same event previously, don't assume the reasons behind the behavior were the same; rather, look even more closely at the process that allowed the event to occur previously.8 It's important to understand that a just culture, although nonpunitive, doesn't release professionals from accountability. Instead, seek to distinguish between errors and breaches of duty, and respond accordingly.


Following an investigation, behaviors are assigned to one of three categories:


* human error. These actions constitute an unintentional outcome that stems from an incorrect choice. In choosing the wrong intervention or by forgetting a crucial step, an employee produces an undesirable result, albeit one that was never meant to happen. These events include forgetting to clean an I.V. site or confusing two medications and running one at a higher rate by accident.


* at-risk behavior. These actions fall outside of normal procedure but are felt to be justified by the employee. Over time, knowledge of correct procedure tends to drift and the professional makes assumptions that his or her behavior is safe. Thoughts such as, "I've started an I.V. without cleaning the site and it didn't become infected" or "I ran the medication faster than normal and it didn't cause harm" make the employee believe that these events will happen again without negative consequences.


* reckless behavior. These actions involve a decision by the professional to purposefully deviate from normal procedure. Disabling an alarm, giving pain medication above the prescribed dosage, or refusing to wear protective equipment are all examples of reckless activities.9 "Reckless" is a legal term that indicates dangerous disregard for safety beyond simple negligence.10 Therefore, the use of the description "intolerable behavior" is preferred by many hospital attorneys.



Console, counsel, or correct

After investigating all of the events leading up to a negative outcome, your response is based on the behavior that caused the outcome. A just culture algorithm is available that allows for consistency across an organization in categorizing behaviors.7 The North Carolina Board of Nursing (NCBON) adopted Marx's principles and created a similar tool, the Complaint Evaluation Tool, which calculates a score indicating whether a facility should counsel a nurse locally or involve the NCBON in guiding its response. This system promotes consistency in responding to errors both within facilities and across the state.11


Responding to human error requires compassion and understanding. The employee should be consoled because he or she is likely feeling guilt and self-doubt from the mistake. The key responses to this behavior are to help the employee understand why he or she made the decision and identify or redesign system components that may have prevented the error. If the mistake resulted from lack of knowledge, further training may be required. Opportunities exist for the employee making the error to assist in designing policies or procedures to prevent it from happening to someone else.


At-risk behaviors require assessment of motivating factors. Neglecting to use gloves may stem from an incorrectly held belief that the nurse isn't at risk from pathogens. However, a shortage of gloves in the required size or placement of the box that makes it difficult to notice may also contribute to the problem. Likewise, leaders should communicate the organization's value of using gloves to prevent employee injury and reinforce the intervention through recognition or incentives for compliance. However, accountability does become a factor. An employee who engages in at-risk behavior should be coached to improve performance. If the behavior persists after coaching, punitive action may be necessary.


Reckless or intolerable behavior indicates a blatant disregard for policy. This behavior is unsafe and remediation is a priority. Based on the choices made, punitive action may be necessary to prevent harm and ensure safe practices.7,8


Make the shift

The shift to a just culture is a slow process that can take years to ingrain into an organization. We've historically responded to errors with retraining or immediate punishment and often neglect to assess processes and human behavior as contributing factors. Frequently, outcomes are used to gauge the severity of punishment. If the same action caused harm in one patient but not another, the response was different. In a just culture, an error receives the same response whether it results in death or never reaches the patient. Likewise, an intolerable act is dealt with the same whether it coincidentally saves a life or results in harm.


The ultimate outcome in a shift to just culture is honest employees who actively report errors and near misses to improve safety. The shift also produces consistent leadership behaviors that result in increased employee satisfaction. By differentiating errors from risk-taking behaviors, hospitals can promote improvement to move healthcare to the ranks of high-reliability organizations.




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6. Miller VB, Jones TL. Creating a Just Culture: A Nurse Leader's Guide. Danvers, MA: HCPro, Inc.; 2011. [Context Link]


7. Marx D. What is just culture? [Context Link]


8. Gibbons L. Just culture transformation: safe choices. [Context Link]


9. Mayer CM, Cronin D. Organizational accountability in a just culture. Urol Nurs. 2008;28(6):427-430. [Context Link]


10. Black HC, Garner BA. Black's Law Dictionary. 9th ed. St. Paul, MN: West Group; 2009. [Context Link]


11. Burhans L, Chastain K, George J. Just culture and nursing regulation: learning to improve patient safety. J Nurs Regul. 2012;2(4):43-49. [Context Link]