Organizations should consistently strive to minimize adverse events and maintain a commitment to safety. This culture of safety encompasses key features such as blame-free environment, encourage collaboration across multidiscipline, and commitment of resources to address safety concerns (Jones & Bartlett Learning, 2014, p. 63). Promoting safety behaviors is encouraged and near misses are valued as opportunities for learning and improvement. For example, if medication error was made by the nurse the error should be reported and followed up with the clinical manager or risk management. At this time the nurse can reflect on what went wrong and what could have been done. Rationales for medication error may be distraction while preparing the
