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- Communication Improvement 2
Culture of Safety
- Just Culture
- Education and Training 1
- Error Reporting and Analysis 5
- Human Factors Engineering 3
- Legal and Policy Approaches 3
- Specialization of Care 1
- Technologic Approaches 2
- Transparency and Accountability 1
Search results for "Just Culture"
- Newspaper/Magazine Article
- Just Culture
Another round of the blame game: a paralyzing criminal indictment that recklessly "overrides" just culture.
ISMP Medication Safety Alert! Acute Care Edition. February 14, 2019;24.
Canadian Medical Protective Association. CMPA Perspective. September 2018;10:8-11.
Frontline leadership should model just culture behaviors to encourage reporting and discussion of error to facilitate improvement. This news article uses a medical administration error to examine whether human error, at-risk behavior, or reckless action on the part of a clinician led to the mistake and explores leadership response to the incident to determine accountability in each type of situation.
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.
ISMP Medication Safety Alert! Acute Care Edition. May 17, 2012;17:1-4; July 12, 2012;17:1-3.
Barger DM, Marella W, Charney FJ. PA-PSRS Patient Saf Advis. December 2011;8:138-143.
This article reports that Pennsylvania health care organizations overestimated their adoption of just culture principles.
ISMP Medication Safety Alert! Acute Care Edition. September 21, 2006;11:1-2.
This second part of this series discusses the three types of behavior involved in error—human error, at-risk behavior, and reckless behavior—including causes of each and appropriate responses.
ISMP Medication Safety Alert! Acute Care Edition. September 7, 2006;11:1-3.
This article discusses the difference between a blame-free and just culture and describes why the latter will effectively sustain and support patient safety efforts.
Quick Safety. April 15, 2019;(48):1-3.
Fatigue, emotional stress, and illness can affect decision-making and lead to misuse of medications. This newsletter article describes the patient safety impacts of drug diversion among health care workers and notes the importance of a culture of constructive reporting to uncover and address this unsafe behavior.
Weber DO. Hosp Health Networks Daily. February 25, 2014.
This article reports on the pervasive challenges to error disclosure and advocates for establishing a just culture to promote these conversations and enhance safety. The author discusses a study that highlighted the need for a patient-centered approach to facilitate peer-to-peer conversations about errors, along with responses solicited regarding a disclosure scenario.
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.
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.