Question

" A Just Culture"

define and describe the 2nd class of errors (at-risk behavior)

give examples and describe

how can it we prevent it?

Answer 1

Just culture specifies to a values-supportive model of common liability. It's a culture that holds organizations accountable for how they respond to staff behaviors fairly and justly and for the systems they design and for delivering care.

Just culture categorizes human behavior to three types:

1. Human error: Unintended action, like a mistake, lapse etc
2. At risk behavior: Behavioral choice, where the risk is increases but the risk is not identified by the staff.
3. Reckless behavior: Behavioral choice, where the staff consciously neglect the risk.

At risk behavior:

At risk behavior is the most common type of just culture behavior and it can present in different patterns.

At risk behaviors are behaviors with low chance for injury, but that has the risk or potential to cause injury.

At risk behavior is defined as “any consciously, or non-consciously controlled behavior with a perceived uncertainty about its outcome, and/or about its possible benefits, or costs for the physical, economic or psycho-social well-being of oneself or others.” -Trimpop (1994)

Eg 1:A nurse was about to administer a cardiac medication (to lower BP) to the patient. She has automatic medication dispenser and she knows the medicine is in third drawer and the container is red capped one. She opens the third drawer, takes out the yellow capped container, and dispense the medicine to the medication cup.

In the above situation, the nurse followed her previous experience, but did not follow the rules of medicine administration. She didn't check the label of the medication, and did not check the expiry date and details of the medication. So in case if another medicine was filled in that drawer by the pharmacist, which is also red capped container, then it will become a serious issue of administering wrong medication.

Even if the medication she administered is a vitamin capsule, without causing much side effects, the cardiac drug which has to be administered will remain un administered and the patient may have problems. The BP medication has been skipped, so the patient will remain hypertensive and risk will rise.

Eg 2: The doctor ordered IV Inj Insulin in 25 % dextrose, to manage hyperkalemia in a patient. On hearing Inj Insulin, the junior nurse prepares and administers subcutaneous injection of Insulin. Here she did not check the prescription for the proper route. Also the nursing supervisor could not guide her properly. Both these may risk the patient for hypoglycemia, if not identified and managed on time.

In both the examples, the mistake was un intentional. In the first case the nurse missed the protocol of checking the label of the medicine, may be to quicken her work, and may be to administer the medicine on right time to the client. She never want to ease up her work to risk the patient. Also the unit was not following a protocol of double checking the medication, which is very important.

In the second example, the junior nurse was not experienced enough and may not be aware of giving Inj Insulin IV. she also wanted to help her senior staff and administered the medicine. The in charge of the unit could not supervise her properly too. This also was unintentional injury risk that happened.

How can we prevent it?

At risk behaviors are not punishable acts, they are the process of learning , according to just culture.

To prevent at risk behaviors, the system has to be more specific in its design,, especially when considering the health care , where the life of the patient can not be risked.

• Increase the awareness of the situation. The situation must be analyzed by the employee, making it clear the causes and the results of the behavior. The risks of the behavior has to be discussed in detail, and how to prevent such a risk in the future.
• Remove incentives for at risk behaviors. Keep a limit for such behaviors, and if it exceeds a certain number, the incentive of that month can be deducted.
• Add incentives for healthy behaviors, if the staff starts maintaining healthy behavior, the incentive can be added back , or appreciated.
• The system has to be specific of its design. If the risk involved not reading the label of a medication before administering, the system has to make it strict on counterchecking of the medication label before administering and documenting it.
• Just culture don't blame individual staff for the mistakes. the mistake responsibility is shared by the system as well as the staff. So better measures and guidance activities are done in order to prevent such mistakes. Direct punishment and sacking is not the style of Just culture.