So, does a “Just Culture” mean there is never repercussions for an individual in a healthcare system? No, as stated above, there is a pillar consisting of understanding the behavior underlying the error. There are “at-risk” behaviors, which are a known violation of a rule or procedure, done in good faith that the violation is inconsequential; or reckless behavior, which is the commission of an error out of intentional disregard for the rule or procedure, its consequence, or both (Wasserman, Redinger and Gibb, 2020). The question is “what should be the repercussion?” Samuel Reis-Dennis (2018) provided an ethical basis for some sort of repercussion for errors based on the ethical idea of a moral imbalance. When someone decides to knowingly break the rules, they are taking advantage of a non-blame culture. This brings about a disadvantage for others. Also, the person who “breaks the rules” is demonstrating a contempt for themselves and for those who follow the rules (Reis-Dennis, 2018). The message communicated is “the rules only apply to others, but not to the person who has broken them” (Reis-Dennis, 2018). He does not advocate punishment for system breakdown, but when members of the healthcare team knowingly break the rules. If there are also system issues, those need to be investigated and handled (Reis-Dennis, 2018). What should the consequences be for “breaking the rules?” Wasserman, Redinger and Gibb (2020) provide some ideas. The recommendations are for medical students who “break the rules,” however they can be applied to all persons working in healthcare. They advocate for two different sets of responses based on the type of “error”. If it was a medical error, there is one set of responses and if there is a lapse in professionalism, there is another set (Wasserman, Redinger and Gibb, 2020). Below is a table adapted from their article, expanded to all healthcare providers, not just medical students. Table 1 Type of Error or Lapse Response Example Medical/Nursing Error Inadvertent human erro r: an error, usually resulting from shortcomings of human cognition, that was unintended. Console. Not hearing a patient call button, forgetting to turn a patient.
Type of Error or Lapse
Response Example
Lapse inProfessionalism No-fault suboptimality : a lapse caused largely by environmental factors, but that could have been handled better by the employee. Nonegregious unprofessionalism : knowing engagement in an unprofessional behavior but with a reasonable and good- faith belief that the violation is minor or inconsequential. Egregious unprofessionalism : knowing violation of a professionalism expectation without a reasonable claim or good-faith belief that the violation is minor or inconsequential.
Affirm, support, advise.
Missing a dressing change because central supply did not deliver the necessary supplies. Being late to work because of a storm where power outages were predicted and alarm clock did not go off.
Remediate. Skipping a mandatory inservice because it is felt the content is redundant.
Discipline.
Logging into a family member or friend’s electronic medication record after training in HIPAA and other policies.
Modified from: Responding to Unprofessional Behavior by Trainees- A “Just Culture” Framework. Wasserman, Redinger, & Gibb, 2020. What is the difference between a “Just Culture” and law enforcement? Both cultures aim to prevent harm to persons/patients and public interest. According to Eng and Schweikart (2020) “Just culture emphasizes the quality or desirability of an individual’s choices and behaviors and apportions corrective actions or discipline on that basis more so than on the severity of the consequences. Criminal law, on the other hand, often focuses on outcomes, and while the law “generally disallow[s] criminal punishment for careless conduct, absent proof of gross negligence” (i.e., a heightened level of negligence that may include recklessness; p781).” This means in a just culture all aspects of the incident are reviewed, however, when examining the same situation through the lens of the criminal system, only the outcome is important.“ Instead of imposing punishments for all categories of failures of duty, a just culture advocates acceptance and support for errors, coaching to change risky behaviors, and discipline or punishment for those whose actions are reckless because they were committed with knowledge of harm or with purposeful intent to harm” (Eng and Schweikart, 2020 p781). Whereas in law enforcement, there may not be “coaching” but punishment, no matter if the behavior was risky (such as driving 5 miles over the speed limit) or with wanton recklessness (driving 50 miles over the speed limit and swerving wildly; Eng and Schweikart, 2020). Even with Just Culture, does the error still effect the healthcare provider? The most obvious victim of a medical error is the patient (and family), however, there is a second victim - the healthcare worker who was involved with the error (White and Delacroix, 2020). The healthcare worker can suffer significant emotional harm and burnout, whether their contribution to the error was preventable
At-risk behavior : a knowing violation of a rule or procedure but with a good-faith belief that the violation is inconsequential.
Coach.
Error caused by failing to scan a patient’s bedside barcode before delivering medication because the system often doesn’t work correctly or ignoring a medication dosage alert in the electronic medical record because such alerts pop up constantly. Failure in completing a procedure or not following policies that directly endanger a patient (e.g., not monitoring a patient after giving a medication that is known to potentially cause harm).
Reckless behavior : commission of an error out of intentional disregard for the rule or procedure, its consequences, or both.
Discipline.
EliteLearning.com/Nursing
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Book Code: ANCCUS2423
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