A Just Culture Approach to Managing Medication Errors

Rogers, Erin; Griffin, Emily; Carnie, William; Melucci, Joseph; Weber, Robert J.

doi:10.1310/hpj5204-308

Cited by 15 publications

(17 citation statements)

References 7 publications

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“…They also prove that the psychological barrier that accompanies reporting, often perceived as whistblowing, was dealt fairly well. It should be added that the trust and the possibility of reporting adverse events and mistakes freely are the basic pillars of just culture (Force et al, 2006;Rogers et al, 2017). As a result of research carried out by Paradiso and Swenney (2017) it was confirmed strong positive correlation between trust and "just culture" alignment.…”

Section: Research Results and Discussionmentioning

confidence: 93%

"Just Culture" From the Perspective of Nursing Personnel

Wiśniewska¹,

Grudowski²,

Marjańska³

2020

Preprint

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Purpose: "Just culture" is an element of safety culture, and in a broader sensea part of quality culture. It is the subject of studies, especially in healthcare. This phenomenon is almost unknown in Polish medical facilities. For this reason, the aim of the article is to present the essence and significance of "just culture" in healthcare. The other aim of the research is to present the results of the validation of "just culture" assessment instrument used to recognize the "just culture" maturity level and evaluate the nurses' beliefs and behaviours in the light of "just culture" criteria. Methodology/Approach: The verified questionnaire consisted of 28 statements in relation to which respondents expressed their opinion on a 5-point Likert scale. The questionnaire was distributed among nurses in one of the largest hospitals in Pomorskie Voivodship, in Poland. The results based on 68 responses were statistically processed with Statistica 13.1 software. Findings: The obtained results allowed to confirm the reliability of the assessment tool, to recognize the level of "just culture" as wisdom (68%) and to indicate strengths and weaknesses of observed beliefs and behaviours. On this basis, improvement actions were proposed. Originality/Value: We use the original, own prepared questionnaire. This is the first study on "just culture" in healthcare in Poland. There are only few studies devoted to patient safety culture in Poland and no research addressed to "just culture" phenomenon, as well in Poland as in Central Europe. The results in this area allow to recommend the assessment tool for other hospitals and seem to help in understanding the essence of "just culture" implementation.

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Section: Research Results and Discussionmentioning

confidence: 93%

"Just Culture" From the Perspective of Nursing Personnel

Wiśniewska¹,

Grudowski²,

Marjańska³

2020

Preprint

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“…A concept called just culture , introduced by Marx (2001) was one reaction to increasing medical error trends; just culture promotes open communication and transparency focused on a purpose. A just culture uses justice to balance punishment and guiltlessness to engender a climate of open communication and impartiality (Rogers et al , 2017). Just culture is an objective of authentic leadership.…”

Section: Theme: Leadership Approachesmentioning

confidence: 99%

Leadership for reducing medical errors via organizational culture: a literature review

Adams

2022

MBE

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Purpose Medical errors have become the third leading cause of death in the USA. Two million deaths from preventable medical errors will occur annually worldwide each year. The purpose of this paper is to find themes from the literature relating leadership styles – leadership approaches in practice – with success in reducing medical errors and patient safety. Design/methodology/approach This review analyzed primary and secondary sources based on a search for the terms leadership OR leadership style AND medical errors OR patient safety using five high-quality health-care-specific databases: Healthcare Administration Database from Proquest, LLC, Emerald Insight from Emerald Publishing Limited, ScienceDirect from Elsevier, Ovid from Ovid Technologies and MEDLINE with Full-Text from Elton B. Stevens Company. After narrowing, the review considered 21 sources that met the criteria. Findings The review found three leadership approaches and four leadership actions connected to successfully reducing medical errors and improving patient safety. Transformational, authentic and shared leadership produced successful outcomes. The review also found four leadership actions – regular checks on the front line and promoting teamwork, psychological safety and open communication – associated with successful outcomes. The review concluded that leadership appeared to be the preeminent factor in reducing medical errors and improving patient safety. It also found that positive leadership approaches, regardless of the safety intervention, led to improving results and outcomes. Research limitations/implications This review was limited in three ways. First, the review only included sources from the USA, the UK, Canada and Australia. While those countries have similar public-private health-care systems and similar socioeconomics, the problem of medical errors is global (Rodziewicz and Hipskind, 2019). Other leadership approaches or actions may have correlated to reducing medical errors by broadening the geographic selection parameters. Future research could remove geographic restrictions for selection. Second, the author has a bias toward leadership as distinctive from management. There may be additional insights gleaned from expanding the search terms to include management concepts. Third, the author is a management consultant to organizations seeking to improve health-care safety. The author’s bias against limited action as opposed to strategic leadership interventions is profound and significant. This bias may generalize the problem more than necessary. Practical implications There are three direct practical implications from this review. The limitations of this review bound these implications. First, organizations might assess strategic and operational leaders to determine their competencies for positive leadership. Second, organizations just beginning to frame or reframe a safety strategy can perhaps combine safety and leadership interventions for better outcomes. Third, organizations could screen applicants to assess team membership and team leadership orientation and competencies. Originality/value This review is valuable to practitioners who are interested in conceptual relationships between leadership approaches, safety culture and reducing medical errors. The originality of this research is limited to that of any literature review. It summarizes the main themes in the selected literature. The review provides a basis for future considerations centered on dual organizational interventions for leadership and safety.

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“…Although a nonpunitive approach is appropriate for most errors, individuals are accountable if they deliberately or repeatedly compromise patient safety. 26…”

Section: Promoting Safety Culturementioning

confidence: 99%

Medicines safety in anaesthetic practice

2019

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By reading this article you should be able to:Discuss the clinical significance of medication errors in anaesthesia. List the causes of medication errors, including human factors. Describe the role of medicine management systems in optimising medicines safety. Outline the aspects of clinical practice that anaesthetists can use to reduce the likelihood of medication errors occurring.Anaesthetic practice involves the preparation and administration of medicines with a high potential for harm in a timecritical fashion. The working environment is distracting and medicines are often used without the support of colleagues or electronic clinical decision tools. There is a reliance on situational awareness, mental focus, and vigilance in order to reduce the chance of medication errors (MEs) occurring. However, human errors are an inevitable outcome of poor human reliability; so it is essential that steps are taken to minimise errors and harm. Robust medicines management is essential for the safe and effective use of drugs by anaesthetists. Processes must be in place to enable reliable and timely access to drugs for clinical efficiency and emergency treatment, whilst also restricting access to mitigate drug misdirection and abuse. 1 This article reviews the medicine management systems and human factors relevant to medicines safety in anaesthetic practice. Classification of MEsMedication errors are 'a failure in the treatment process that lead to, or have the potential to lead to, harm to the patient'. 2 Classification of errors can be approached in a variety of ways, for example according to root cause or clinical outcome. In order to prioritise effectively those areas in need of risk mitigation strategies, critical incident reporting data can be used to identify trends in particular types of MEs. Some of the ways that errors can be categorised are listed in Table 1. Clinical significance of medicines safetyThe reported incidence of MEs in anaesthetic practice varies widely between studies, partly because of varying definitions and study methodologies. In studies that rely on anaesthetists Steve Webber FRCA in a consultant in anaesthesia and critical care at Sheffield Teaching Hospitals. His clinical interests are clinical governance and patient safety, critical care, and anaesthesia for urological surgery.

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A Just Culture Approach to Managing Medication Errors

Cited by 15 publications

References 7 publications

"Just Culture" From the Perspective of Nursing Personnel

"Just Culture" From the Perspective of Nursing Personnel

Leadership for reducing medical errors via organizational culture: a literature review

Medicines safety in anaesthetic practice

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