Introduction The main objective of healthcare professionals is to provide the best quality of patient care and the highest level of patient safety. To achieve that objective, there are many organizations that help to improve the quality of care. One of the best examples is the Joint Commission. Unfortunately, the healthcare system is not free from total risks. In healthcare activities, there are possible errors, mistakes, near miss and adverse events. All of those negative events are unfortunately preventable. But, it is clear that errors caused in healthcare thousands of death in the United States. In healthcare systems, there is a concept of fair and just culture. That concept is important to manage the risk. In any organization, errors
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Just Culture I gave the following example in one of my post: A nurse can for example make a mistake by giving an IV injection in IM. He or she should honestly report that mistake. In the just culture concept; instead of blaming directly the nurse, an investigation process will be initiated to determine the real cause of the mistake. The mistake could be attributed to the negligence at any level; it could be attributed to a system failure. Then, the concept will fairly find out where the problem was and then, it will try to fix it.
Because errors are inherent to human’s nature, blaming or immediately terminating an employee involved in an error is not the right approach. Punitive approach is not effective. Instead, training and educational approach are the best way to handle adverse event based on the Just Culture concept. “In 1997, John Reason wrote that a Just Culture creates an atmosphere of trust, encouraging and rewarding people for providing essential safety-related information” (American Nurses Association …show more content…
Cataldo 2011 said: “The concept of a fair and just culture refers to the way an organization handles safety issues. Human are fallible; they make mistakes. In a just culture, ‘hazardous’ human behavior such as staff errors, near-misses and risky actions are identified and discussed openly in hopes of finding ways to improve processes and systems – not to identify and punish the individual.” The same author stated that: “The moral imperative is to deliver the safest health care by taking account of human fallibility and the imperfections of the system.” The role of punitive sanction is persuasive. It can be implemented. But, it is not always effective. The threat and/or application of punitive sanction as a remedy of human error can sometimes help the system of safety efforts; but not all the time. It can even hurt the system
Just Culture I gave the following example in one of my post: A nurse can for example make a mistake by giving an IV injection in IM. He or she should honestly report that mistake. In the just culture concept; instead of blaming directly the nurse, an investigation process will be initiated to determine the real cause of the mistake. The mistake could be attributed to the negligence at any level; it could be attributed to a system failure. Then, the concept will fairly find out where the problem was and then, it will try to fix it.
Because errors are inherent to human’s nature, blaming or immediately terminating an employee involved in an error is not the right approach. Punitive approach is not effective. Instead, training and educational approach are the best way to handle adverse event based on the Just Culture concept. “In 1997, John Reason wrote that a Just Culture creates an atmosphere of trust, encouraging and rewarding people for providing essential safety-related information” (American Nurses Association …show more content…
Cataldo 2011 said: “The concept of a fair and just culture refers to the way an organization handles safety issues. Human are fallible; they make mistakes. In a just culture, ‘hazardous’ human behavior such as staff errors, near-misses and risky actions are identified and discussed openly in hopes of finding ways to improve processes and systems – not to identify and punish the individual.” The same author stated that: “The moral imperative is to deliver the safest health care by taking account of human fallibility and the imperfections of the system.” The role of punitive sanction is persuasive. It can be implemented. But, it is not always effective. The threat and/or application of punitive sanction as a remedy of human error can sometimes help the system of safety efforts; but not all the time. It can even hurt the system