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- Communication Improvement 1
- Culture of Safety
- Education and Training 1
- Error Reporting and Analysis 2
- Human Factors Engineering 2
- Specialization of Care 1
- Technologic Approaches 1
- Transparency and Accountability 1
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Stabile M, Webster CS, Merry AF. APSF Newsletter. Fall 2007;22:44-47.
To reduce anesthesia administration errors, the authors propose changing the organizational culture to foster a better understanding of human error and to adopt lasting safety principles.
No more blame & shame: developing event-reporting systems may go a long way to reducing patient care errors in EMS.
Rajasekaran K, Fairbanks RJ, Shah MN. EMS Mag. 2008 Sep;37:61-67.
This article describes how applying a just culture and systems approach to adverse events may help change the "blame-and-shame" mentality in emergency medical service provision.
Blum K. Pharmacy Practice News. November 16, 2011.
Exploring the impact of medication errors on clinicians, this article discusses efforts to support second victims affected by medical error.
Journal Article > Commentary
Duthie EA. Nurs Manage. 2018;49:18-21.
A just culture balances organizational context with appropriate accountability after an error. This commentary illustrates the difference between blame and accountability as applied to a near miss. The author highlights how accountability enables individual and organizational learning through constructive examination of error.