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In healthcare, patient safety is everything done to ensure the facilitation of safe, efficient care. However, even in the best of circumstances, errors and near misses can occur. Most errors are caused by system-related processes; however, it is important that all errors and near misses are reported. These reports help to ensure the root causes are identified and fixed to prevent future harm. The more information an organization has about an incident the better, especially if there is a growing trend of similar incidents occurring in a practice or facility. Trends can be tracked to see what issues are contributing to the overall problem.
How can an organization encourage the accurate reporting of near misses and errors without a retaliation approach to the reporting employee(s)? That is where the concept of “just culture” comes in. This concept was identified in the early 2000s as a way to create trust while gaining important safety information about system and behavioral processes. While it promotes a trusting and fair environment, it also holds those individuals accountable for gross negligence or deliberately engaging in unsafe clinical practice.
In this Assignment, you will be reflecting on the meaning of a “just culture.” During your reflection, consider examples of “just culture” and how that impacted system processes. You will share your thoughts on the topic.
To prepare:
Review the Required Learning Resources
Consider what you think “just” culture means
Reflect on examples of “just” culture in your practice
The Assignment (1 page)
Submit a journal reflection in which you answer the following:
What is a “just” culture? What is not a “just” culture?
Provide an example of a “just” culture in your own practice. A just culture also holds people appropriately accountable where there is evidence of gross negligence or deliberately acting in an unsafe way. Provide an example in which a healthcare provider was held accountable for a negligent act. If you do not have a personal experience, share an experience that has been published in the news.
LEARNING RESOURSES:
American Nurses Association. (2010). Position statement: Just culture. https://www.nursingworld.org/~4afe07/globalassets/practiceandpolicy/health-and-safety/just_culture.pdf
Murray, J. S., Clifford, J., & Lee, J. K. (2022). Implementing just culture to improve patient safety.Links to an external site. Military Medicine, 188(7–8), 1596–1599. https://academic.oup.com/milmed/article/188/7-8/1596/6589441
Paradiso, L., & Sweeney, N. (2019). Just culture: It’s more than policy.Links to an external site. Nursing Management, 50(6), 38–45. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6716556/pdf/numa-50-38.pdf
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