- Review the information on just culture presented in the Learning Resources.
- For this discussion, you will use the Regulatory Decision Pathway found in Russell, K. A. & Radtke, B. K. (2014).
- Examine an adverse event at the unit level in your organization or one with which you are familiar and apply the Regulatory Decision Pathway.
- Compare the findings of the Regulatory Decision Pathway to what actually happened at the unit in your organization. Was the event deemed: bad intent, reckless, at risk, or human error? According to the pathway, do you now think it was the correct action?
- Think about how a nurse leader–manager may use just culture as a framework to create or maintain a focus on accountability and outcomes throughout a group. What actions could be taken if a systems–related error was made or if an error resulted from risky behavior?
- How might role conflict and/or ambiguity have contributed to the situation?
By Day 3
Post a description of an adverse event in your organization and your analysis of the issue using the Regulatory Decision Pathway. Explain how role conflict or ambiguity might have influenced this situation. Apply the principles of just culture as you explain how you, as the group’s manager, would handle the situation.
Expert Solution Preview
Introduction:
In my role as a medical professor responsible for creating college assignments and evaluating student performance, I have designed lectures and assessments that delve into various aspects of healthcare, including patient safety and adverse events. The topic of just culture and its application in handling adverse events is one that is particularly relevant in today’s healthcare setting. In this response, I will provide an analysis of an adverse event in my hypothetical organization, considering the principles of just culture and how role conflict or ambiguity may have contributed to the situation. Additionally, I will outline the actions I, as the group’s manager, would take to address the situation.
Adverse Event Description and Application of the Regulatory Decision Pathway:
In my organization, an adverse event occurred at the unit level involving a medication administration error. The Regulatory Decision Pathway provides a framework to analyze the event and determine the appropriate level of accountability and disciplinary action. According to the pathway, the event will be deemed as either bad intent, reckless, at risk, or human error.
Upon examining the situation, it was determined that the adverse event was a result of human error. The nurse involved inadvertently administered a medication to the wrong patient due to distractions and an overwhelming workload. The error was not intentional, but rather a result of a lapse in attention and fatigue. Applying the Regulatory Decision Pathway, it is evident that the correct action would be to classify this event as human error, rather than bad intent, recklessness, or at-risk behavior.
Role Conflict and Ambiguity:
Role conflict and ambiguity may have contributed to this adverse event. The nurse involved may have experienced conflicting demands, such as the pressure to complete tasks quickly while also ensuring accuracy in medication administration. Additionally, there may have been ambiguity regarding the proper protocol for handling distractions or seeking assistance in situations of increased workload.
Applying Just Culture Principles:
As the group’s manager, I would approach this situation using the principles of just culture. Just culture recognizes that individuals may make errors, and it emphasizes learning from those errors rather than solely blaming individuals. In this case, I would initiate a non-punitive approach to address the medication administration error.
Firstly, I would provide support to the nurse involved by ensuring access to resources aimed at enhancing attention and reducing distractions. This may include implementing strategies such as medication safety checks or providing additional staffing during high-demand periods. By addressing role conflict and ambiguity, we can create an environment that prioritizes patient safety and minimizes the occurrence of similar errors in the future.
Furthermore, I would encourage open communication and dialogue among the healthcare team to foster a culture of learning and accountability. Team members would be encouraged to report any near misses or errors without fear of retribution, allowing for the identification of system-related issues and the implementation of preventive measures.
Conclusion:
In conclusion, the analysis of the adverse event using the Regulatory Decision Pathway revealed that the event was the result of human error. Role conflict and ambiguity likely played a role in contributing to the situation. By applying the principles of just culture, such as supporting individuals involved and addressing system-related issues, as the group’s manager, I would strive to create a culture of accountability and learning, prioritizing patient safety throughout the organization.
