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- Culture of Safety
- Education and Training 2
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- Legal and Policy Approaches 5
- Quality Improvement Strategies 3
- Technologic Approaches 1
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Health Care Providers
- Nurses 1
- Non-Health Care Professionals 5
Search results for "Latent Errors"
- Just Culture
- Latent Errors
Journal Article > Commentary
Selected medication safety risks that can easily fall off the radar screen—part 1, part 2, and part 3.
Grissinger M. P T. 2018;43:521,567;585-586;645-646,666.
Although best practices that support safe and reliable medication therapy exist, they are not uniformly embedded in care delivery. This three-part series discusses medication safety risks and highlights topics such as wrong-patient orders, inadequate patient understanding of drug instructions, and poor lighting.
Journal Article > Study
Development of the just culture assessment tool: measuring the perceptions of health-care professionals in hospitals.
Petschonek S, Burlison J, Cross C, et al. J Patient Saf. 2013;9:190-197.
The importance of safety culture in medicine is well recognized and health care institutions now regularly administer validated measurement tools such as AHRQ's Patient Safety Culture Survey. Although early safety culture efforts focused on shifting from a punitive approach to a systems-based strategy to reduce medical errors, growing support has emerged for the establishment of a just culture that balances no-blame with appropriate accountability. This study sought to develop a survey that would measure individual perceptions of just culture in a hospital setting. The research team created a 27-item survey, which displayed adequate theoretical structure and internal reliability. This instrument now needs to be validated in other settings and among broader populations.
Journal Article > Commentary
Wachter RM, Pronovost PJ. N Engl J Med. 2009;361:1401-1406.
An early focus of the patient safety movement was a shift from the traditional culture of individual blame to one that investigated errors as the failure of systems, popularized by adoption of James Reason's Swiss cheese model of organizational accidents. In recent years, there has been some backlash against a unidimensional systems-focused model, with past commentaries exploring the tension between a "no blame" culture and individual accountability. Articles in this genre have considered this tension in the educational setting, and a popular construct involves a just culture framework, which differentiates "no blame" from blameworthy acts. This commentary, written by two of the leaders in the safety field, further explores the relationship between blame and accountability, discusses why enforcement of safety standards tends to be lax (particularly in cases involving physicians), and proposes a working balance that not only promotes a safety culture but also safe patient care. The authors highlight hand hygiene non-compliance as an example of a behavior that should be managed through an accountability framework, with providers held accountable for failure to adhere to a known safety standard. They also offer suggested penalties (mostly involving suspension of clinical privileges) for repeated failures to comply with hand hygiene and other established safe practices.
Perspectives on Safety > Interview
Just Culture, October 2007
An engineer and an attorney by training, David Marx, JD, is president of Outcome Engineering, a risk management firm. After a career focused on safety assessment and improvement in aviation, he has spent the last decade focusing on the interface between systems engineering, human factors, and the law. In 2001, he wrote a seminal paper describing the concept of just culture, which became a focal point for efforts to reconcile notions of "no blame" and "accountability." He has gone on to form the "Just Culture Community" to address these issues at health care institutions around the country.
Perspectives on Safety > Perspective
with commentary by Alison H. Page, MS, MHA, Just Culture, October 2007
We've all been there...something goes wrong, a patient is harmed, and we, as medical directors, managers, and administrators, are forced to judge the behavioral choices of another human being. Most of the time, we conduct this complex leadership function guided by little more than vague policies, personal beliefs, and intuition. Frequently, we are frustrated by the fact that many other providers have made the same mistake or behavioral choice, with no adverse outcome to the patient, and the behavior was overlooked. Quite understandably, the staff is frustrated by what appears to be inconsistent, irrational decision-making by leadership. The "just culture" concept teaches us to shift our attention from retrospective judgment of others, focused on the severity of the outcome, to real-time evaluation of behavioral choices in a rational and organized manner.
Journal Article > Commentary
Larsen D, Cole R, Higton P. Nurs Stand. 2007;21:35-40.
By introducing several scenarios that illustrate the effective use of a decision-making tree, the authors emphasize the importance of fair response to medication error at both the individual and system levels.
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.
Legislation/Regulation > Organizational Policy/Guidelines
Boston, MA: Dana-Farber Cancer Institute.
Dana-Farber Cancer Institute defines a "just culture" and illustrates how to implement and sustain it.