Just Culture and its critical link to patient safety—part 1 and part 2.

Newspaper/Magazine Article

Just Culture and its critical link to patient safety—part 1 and part 2.

July 25, 2012

ISMP Medication Safety Alert! Acute Care Edition. May 17, 2012;17:1-4; July 12, 2012;17:1-3.

This newsletter article series presents national data from the AHRQ Hospital Survey on Patient Safety Culture to help hospitals assess their safety and establish a just culture.

Free full text: Part 1

Free full text: Part 2

Related Resources From the Same Author(s)

Raising the index of suspicion: red flags that represent credible threats to patient safety.

August 8, 2012

Good intention, uncertain outcome...our take on physician dispensing in offices and clinics.

March 21, 2012

A shortage of everything except errors: harm associated with drug shortages.

May 2, 2012

Side tracks on the safety express. Interruptions lead to errors and unfinished…wait, what was I doing?

December 19, 2012

Reduce readmissions with pharmacy programs that focus on transitions from the hospital to the community.

November 28, 2012

Mismatched prescribing and pharmacy templates for parenteral nutrition (PN) lead to data entry errors.

July 18, 2012

Results of ISMP survey on high-alert medications: differences between nursing, pharmacy, and risk/quality/safety perspectives.

February 22, 2012

Sterile compounding tragedy is a symptom of a broken system on many levels.

October 31, 2012

Results of our survey on drug storage, stability, compatibility, and beyond use dating.

April 4, 2012

ISMP 2007 survey on high-alert medications. Differences between nursing and pharmacy perspectives still prevalent.

May 30, 2007

With oral chemotherapy, we simply must do better!

July 30, 2014

Heparin errors continue despite prior, high-profile, fatal events.

August 6, 2008

Prescription drug time guarantees and their impact on patient safety in community pharmacies.

September 19, 2012

ADC survey shows some improvements, but unnecessary risks still exist.

February 6, 2008

Double key bounce and double keying errors.

January 31, 2006

Is an indication-based prescribing system in our future?

November 30, 2016

Safety enhancements every hospital must consider in wake of another tragic neuromuscular blocker event.

January 23, 2019

Getting closer to the bull's eye: 2014–2015 Targeted Medication Safety Best Practices.

February 25, 2015

Beware of basal opioid infusions with PCA therapy.

March 25, 2009

Follow ISMP guidelines to safeguard the design and use of automated dispensing cabinets (ADCs).

March 4, 2009

Survey results: smart pump data analytics pump metrics that should be monitored to improve safety.

July 25, 2018

Preventing errors when preparing and administering medications via enteral feeding tubes.

December 7, 2022

Mail service and community pharmacies must work in tandem.

November 30, 2005

Smart pump custom concentrations without hard "low concentration" alerts.

March 14, 2012

Inappropriate use of pharmacy bulk packages of IV contrast media increases risk of infections.

October 3, 2012

November 14, 2007

Latent and active failures perfectly align to allow a preventable adverse event to reach a patient.

February 1, 2023

Safety requires a state of mindfulness.

March 22, 2006

Failure to cap IV tubing and disinfect IV ports place patients at risk for infections.

August 15, 2007

Practitioners agree on medication reconciliation value, but frustration and difficulties abound.

July 26, 2006

High-reliability organizations (HROs): what they know that we don't (Part I).

July 27, 2005

Practitioners anticipate punitive action from licensing bodies.

June 1, 2005

Please don't sleep through this wake-up call.

March 27, 2005

Drug shortages threaten patient safety.

August 11, 2010

DTaP–Tdap mix-ups now affecting hundreds of patients.

July 14, 2010

Oral solid medication appearance should play a greater role in medication error prevention.

August 10, 2011

Too many abandon the "second victims" of medical errors.

July 27, 2011

Misidentification of alphanumeric symbols in both handwritten and computer-generated information.

July 15, 2009

ISMP National Vaccine Errors Reporting Program: one in three vaccine errors associated with age-related factors.

August 10, 2016

Correct use of inhalers: help patients breathe easier.

July 27, 2016

Survey suggests possible downward trend in identifying key drugs/drug classes as high-alert medications.

July 16, 2014

Use of tall man letters is gaining wide acceptance.

August 13, 2008

Epidural-IV route mix-ups: reducing the risk of deadly errors.

July 16, 2008

High-reliability organizations (HROs): what they know that we don't (Part II).

August 24, 2005

Risk Evaluation and Mitigation Strategy (REMS) Programs and Medication Safety: Parts I and II.

August 9, 2023

Multiple latent failures align to allow a serious drug interaction to harm a patient.

May 18, 2011

Smart pump custom concentrations without hard "low concentration" alerts can lead to patient harm.

June 20, 2018

Hardwiring safety into the computer system: one hospital's actions to provide technology support for U-500 insulin.

May 18, 2016

The absence of a drug–disease interaction alert leads to a child's death.

June 3, 2015

Fatal PCA adverse events continue to happen...better patient monitoring is essential to prevent harm.

June 19, 2013

Administering a saline flush "site unseen" can lead to a wrong route error.

May 29, 2013

Despite technology, verbal orders persist, read back is not widespread, and errors continue.

May 31, 2017

Survey on LASA drug name pairs: who knows what’s on your list and the best ways to prevent mix-ups?

June 3, 2009

More can be done to alleviate errors associated with pharmaceutical product labeling and packaging.

May 19, 2021

Considering insulin pens for routine hospital use? Consider this...

May 28, 2008

Progress with preventing name confusion errors.

August 22, 2007

Ongoing, preventable fatal events with fentanyl transdermal patches are alarming!

July 18, 2007

Heed this warning! Don't miss important computer alerts.

February 21, 2007

Safety committees need to proactively address the risk of accidental cerebral injection of intravenous (IV) drugs.

August 11, 2021

Medication orders with future start dates: how far away is too far?

July 27, 2022

During the pandemic, aspire to identify and prevent medication errors and to avoid blaming attitudes.

September 30, 2020

Pump up the volume: tips for increasing error reporting and decreasing patient harm.

September 8, 2021

Remote CPOE error—a situation that's more than remotely possible.

June 13, 2007

Action needed to prevent dangerous heparin-insulin confusion.

May 16, 2007

Assessing medication safety in settings not designated solely for pediatric patients.

June 28, 2023

The differences between human error, at-risk behavior, and reckless behavior are key to a just culture.

July 1, 2020

Results of survey on pediatric medication safety—part 1 and part 2.

June 17, 2015

Disrespectful behavior in healthcare...have we made any progress in the last decade?

July 17, 2013

A lot happens when you report a hazard or error to ISMP—there’s no “black hole” here!

December 4, 2019

Over-the-top risky: overuse of ADC overrides, removal of drugs without an order, and use of non-profiled cabinets.

November 13, 2019

Building a case for medication reconciliation.

May 3, 2006

IV potassium given epidurally: getting to the "route" of the problem.

April 19, 2006

IV vincristine survey shows safety improvements needed.

March 8, 2006

Pharmaceutical industry and medical device companies: part of the solution?

November 29, 2006

Harmful errors: how will your facility respond?

October 18, 2006

Fatal misadministration of IV vincristine.

December 14, 2005

If safety is your yardstick, measuring culture from the top down must be a priority.

April 4, 2007

Fluorouracil error ends tragically, but application of lessons learned will save lives.

October 3, 2007

Lack of standard dosing methods contributes to IV errors.

September 5, 2007

Errors with injectable medications: unlabeled syringes are surprisingly common!

November 28, 2007

Error-prone conditions that lead to student nurse-related errors.

October 31, 2007

Potassium may no longer be stocked on patient care units, but serious threats still exist!

October 17, 2007

Resolving human conflicts when questions about the safety of medical orders arise.

March 26, 2008

USA Today news series: clarifying the issues and embracing community pharmacy safety.

March 12, 2008

Keeping patients safe from iatrogenic methadone overdoses.

February 27, 2008

Reducing patient harm from opiates.

March 7, 2007

The five rights: a destination without a map.

February 7, 2007

Your attention please... designing effective warnings.

September 6, 2006

Rapid response team activation by patients can mitigate errors.

June 21, 2006

Loud wake-up call: unlabeled containers lead to patient’s death.

March 27, 2005

Fatal gas line mix-up: How to avoid making this "gastly" mistake.

March 6, 2005

Eric Cropp weighs in on the error that sent him to prison.

December 16, 2009

Order scanning systems may pull multiple pages through the scanner at the same time, leading to drug omissions.

November 18, 2009

Oral syringes: a crucial and economical risk-reduction strategy that has not been fully utilized.

November 4, 2009

Preventing medication errors during codes.

February 23, 2011

Guidelines for timely medication administration: response to the CMS "30-minute rule."

January 26, 2011

ISMP updates its list of drug name pairs with Tall man letters.

December 1, 2010

Drug shortages: national survey reveals high level of frustration, low level of safety.

October 6, 2010

CMS 30-minute rule for drug administration needs revision.

September 22, 2010

Electronic prescribing vulnerabilities: height and weight mix-up leads to dosing error.

September 8, 2010

Related Resources

Bad behavior in healthcare: an insidious threat to patients, staff, and organizations.

April 17, 2024

National Healthcare Quality and Disparities Reports.

January 9, 2024

React, reframe and engage. Establishing a receiver mindset for more effective safety negotiations.

November 8, 2023

Achieving a successful patient safety program with implementation of a harm reduction strategy.

October 25, 2023

Individual characteristics that promote or prevent psychological safety and error reporting in healthcare: a systematic review.

May 10, 2023

What's changed 1 year after RaDonda Vaught's conviction?

April 12, 2023

Listening, Learning, Responding to Concerns.

April 12, 2023

Health care professionals' perceptions of unprofessional behaviour in the clinical workplace.

March 1, 2023

Lessons learned from the RaDonda Vaught ruling.

March 1, 2023

A failure in the medication delivery system-how disclosure and systems investigation improve patient safety.

January 11, 2023

Position Statement on Criminalization of Medical Error and Call for Action to Prevent Patient Harm from Error.

October 26, 2022

The barriers and enhancers to trust in a just culture in hospital settings: a systematic review.

August 17, 2022

Criminalization of human error and a guilty verdict: a travesty of justice that threatens patient safety.

April 20, 2022

Nurses: Guilty verdict for dosing mistake could cost lives.

April 13, 2022

Improving self-reported empathy and communication skills through harm in healthcare response training.

January 26, 2022

Pointing fingers: verbosity of patient safety narratives is associated with attribution of blame.

December 8, 2021

Development and expression of a high-reliability organization.

December 1, 2021

10 Leadership mindsets for high reliability organizations. How to empower caregivers and engage patients in patient safety.

April 14, 2021

During the pandemic, aspire to identify and prevent medication errors and to avoid blaming attitudes.

September 30, 2020

Preserving organizational resilience, patient safety, and staff retention during COVID-19 requires a holistic consideration of the psychological safety of healthcare workers

July 8, 2020

The differences between human error, at-risk behavior, and reckless behavior are key to a just culture.

July 1, 2020

Drug diversion and impaired health care workers.

May 1, 2019

The association between organizational culture and the ability to benefit from "just culture" training.

March 6, 2019

Another round of the blame game: a paralyzing criminal indictment that recklessly "overrides" just culture.

February 27, 2019

'Just culture': improving safety by achieving substantive, procedural and restorative justice.

May 25, 2016

AHRQ Communication and Optimal Resolution (CANDOR) Toolkit.

May 25, 2016

Hospital Survey on Patient Safety Culture: 2016 User Comparative Database Report.

May 11, 2016

Annual Perspective

Accountability in Patient Safety

January 1, 2015

From Science to Implementation: AHRQ's Program to Prevent HAIs—Results and Lessons.

November 5, 2014

Preventing Healthcare-Associated Infections: Results and Lessons Learned from AHRQ's HAI Program.

October 29, 2014

See More About The Topic

Hospitals

Health Care Executives and Administrators

General Internal Medicine

Hospital Medicine

Psychological and Social Complications

Just Culture and its critical link to patient safety—part 1 and part 2.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Just Culture and its critical link to patient safety—part 1 and part 2.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site