A Culture of Safety - Essay Example

? A Just Culture: A Culture of Safety Introduction Human error, especially in the medical field, can have serious consequencesto the patient, hospital employee and the hospital as a whole. The traditional approach to errors in such a setting focused on punitive measures often aimed at the employee. However, as management models have continued to evolve, people have recognized that an error can only be prevented if it is known. This is the basis of the just culture in nursing, which acts as a bridge between the traditional approach and a situation in which no one bears the responsibility of errors. The just culture enables an organization as well as its employees to learn from mistakes and create a system that minimizes chances of error. This paper explores the just culture in a nursing setting and its impact on the safety of the patients. The Role of the Nurse in identifying Potential and Real Threats Patient safety is the core mission of every healthcare institution. Nurses have a role in ensuring that the patients in a hospital setting are catered to adequately to ensure their safety. They are obligated to identify, whenever possible, the risks that patients face while in the health institution. One way of identifying threats against the health of a patient would be to open the communication channels in the hospital. This would enable a nurse to report to the administration about a threat to the safety of the patients. Previously, the punitive system in such a setting inhibited such reporting and nurses only identified threats which they would not be able to hide. The just culture enables a nurse to identify a risk which may have occurred due to an error and report the threat in the appropriate manner. This increases patient safety as adequate measures can be taken to remedy the situation. This role of the nurse is, therefore, in line with the just culture as proposed by Reason (American Nurses Association, 2010). Steps in Minimizing or Eliminating Threats Rules and Regulations Following instructions that are set by the organization should be a priority for all nurses. Managers, according to Lazarus (2011), must put systems in place that will enable the nurses to carry out their roles in the institution effectively. These systems are part of the rules that are set by the nursing leadership to provide maximum efficacy at the work place. Nurses should therefore adhere to these set rules and regulations, in order to minimize the chances of errors happening at the work place. Most of the systems in place are tested and tried, meaning they have been found to reduce the number of errors that people can make at the work place. Although human errors do occur, a continuous improvement of the system, as proposed in the just culture will lead to the system achieving maximum efficiency. Acting with regard to these rules will minimize or even eliminate the chances of error. Nurses should only act contrary to these rules when there is evidence that acting according to them presents a threat to the patient (Lazarus, 2011). Attending Seminars Seminars and other meetings organized by the institution to sensitize employees in patient safety are a valuable resource to nurses. Policies that are proposed and passed during these meeting have an effect on the performance of the nurses, and it is therefore important that nurses attend these meetings. This way, they will be conversant with the rules and regulations, as well as contribute to the development of these policies such that the rules will also be in favor of the nurses. Patient safety can be maximized through such meetings since the stakeholders agree on the most effective means of achieving that goal. Nurses mostly deal with patients directly and are obligated to ensure the safety of the patient. By attending these seminars, they increase their knowledge and learn how to incorporate the new policies with their expertise. This is an important aspect for the safety of the patient and nurses should take this measure to minimize threats to patient safety. Such training will eliminate the chances of negligent conduct as described by Morris (Morris, 2011). Collaboration Collaborating with other nurses and departments also plays a key role in eliminating threats to the safety of the patient. Nurses should take this step seriously and ensure that they provide information to other nurses and also obtain information whenever necessary. The goal of the institution is to improve patient safety. It is therefore important that nurses should seek expertise which they do not posses in order to minimize the risk to the patient. This collaborative effort will result to better treatment for the patient as well as increased expertise for the nurse. In order to learn, the nurse should be able to acknowledge his or her weakness and thus be exempted from error. This exemption will lead to minimized threats to the patient, improve safety as well as eliminate human errors and reckless behavior. Teamwork is essential in such a setting, thus the nurse should be able to work with other nurses to improve the safety of the patient. Evaluation of Patient Safety Patient safety in the just culture can be evaluated through examination of behavioral choices of the nurse. The importance of using this approach is because it enables errors to be classified differently, after which an error can then be explored on an individual basis. This means that the nursing leadership does not put the blame on the nurse but rather attempts to find out what was the main cause of the system failure. The systems employed in the healthcare environment must be able to support the role of the nurse in the institution as well as reduce the chances of threats occurring. Using this tool for evaluation will eliminate all possible threats that may be posed by the system. This will mean that exploration of errors will be effective and the behavior of nurses towards patients can be used to determine patient safety in the healthcare environment. Reporting of errors and threats in the healthcare setting is one of the ways of evaluating patient safety. The errors reported can be classified either as human errors or other form of errors. This will enable the leadership in an institution to evaluate whether patients have been safe or whether their safety has been compromised either by the system or through reckless behavior. It is, therefore, vital to open the communication channels in the organization and make maximum use of the just culture which advocates for punitive measures in case of reckless errors. This system would enable the organization to evaluate its performance with regard to patient safety through timed evaluation of the reports. Promoting Patient Safety Reporting Procedures Achieving patient safety in a health institution requires several measures to be put in place. One of these measures is to ensure that the system employed in the hospital is well designed to counter any threats. Continuous improvement of the system is vital to development of patient safety. As a practitioner, I would employ measures that would capture employee errors that pose a threat to the safety of the patient. These errors can then be analyzed and used as the guiding rules in the improvement of the current system in the healthcare setting. Learning is an important part of improvement and I would put measures in place to ensure that learning takes place. Since the just culture emphasizes that human errors can be minimized through improvement of work systems, I would improve on the systems through liberalization of the communication channels available in the health facility. Teamwork Teamwork is essential for the safety of the patient. To improve patient safety, I would conduct seminars sensitizing people on the importance of teamwork. The interest of patients must be fully catered for and therefore, nurses must ensure that they work together to maximize patient safety in the institution. As in all other areas, experience is an important part of any organization. Collaboration between new nurses and more experienced nurses would form a vital part of the safety process in the institution. The inexperienced nurses would learn from the other nurses. This would reduce the chances of errors occurring and the threats to the patients from inexperience would be neutralized. This would also provide a learning opportunity to the new nurses. Feedback New processes and systems of work are experienced by the people working with them. I would put feedback mechanisms in the institution to ensure that people reported back on the experience of new procedures and how they can be enhanced to achieve the set goals. This will provide the whole organization as well as other nurses with information regarding the new systems and methods of improving the new system. Minimal resistance from the internal organization would be vital in achieving the goals of the organization. The feedback mechanism will be secure and will not victimize any person in the institution. This will help the institution to continuously improve its system, to incorporate the needs of the patients as well as those of the nurses. Conclusion The just culture is an important aspect of patient safety. The roles of people in a healthcare setting are well defined and errors are classified according to cause rather than culprit. This enables the organization to improve on the systems that support its work model and thus reduce the threats that the organization faces with regard to patient safety. Some of the measures that can be employed by the nurses to ensure that they minimize errors and threats to the patients embrace teamwork, adherence to rules and regulations as well as attending policy meetings. These measures are important in that they eliminate causes of errors in the institution and thus uphold patient safety. The just culture is a relevant aspect of the hospital setting in the modern world, as it advocates for a system that shares the blame between the system and irrationality on the nurses. In summary, the just culture can improve patient safety as well as enhance nurse performance in a health institution. References AmericanNursesAssociation. (2010). Just Culture. Retrieved from http://www.justculture.org/Downloads/ANA_Just_Culture.pdf Lazarus, I. R. (2011). On the Road to Find Out... Transparency and Just Culture Offer Significant Return on Investment. Journal of Healthcare Management , 56 (4), 223-27. Morris, S. (2011). Just culture-changing the environment of healthcare delivery. Clinical Laboratory Science , 24 (2), 120-24. Read More