Article Summary
Mayer, C. & Cronin, D. (2008). Organizational accountability in a just culture. Urologic Nursing, 28(6), p. 427-430.
- Contribution of system factors to the occurrence of adverse events in medical environments.
- Importance of reporting and analysis of sentinel events.
- Health care system factors
- Components of a culture of safety: learning culture, reporting culture, and a just culture.
- Barriers to a just culture.
- Description of a just culture
- Tools for determining culpability for adverse events
- Types of behaviours involved in error
- System analysis
- A just culture encourages reporting of errors, learning from errors, and enhancement of safety. In a just culture, staffs are not afraid of reporting errors when they occur because they are confident that they will be treated fairly. Reporting fosters the conduct of comprehensive root cause analysis of sentinel events and in effect, identification of system and individual factors that contribute to the occurrence of errors. This in turn fosters improvements to policy and practice that in health care environments, improve patient safety.
- A just culture distinguishes between the causes of human errors: some are inadvertent, intentional, and others occur due to negligence. In distinguishing between the various causes of human errors, it ensures that appropriate disciplinary actions are taken against staffs who act recklessly or negligently.
- It fosters a shared value of patient safety. A just culture creates an environment where both nurse leaders and front-line staffs feel responsible for upholding patient safety. As a result, the staffs become comfortable and proactive in identifying and reporting safety concerns.
Cons of a Just Culture
- The current legal standards do not support a just culture. They emphasis on individual culpability and hence staffs wary of potential litigation may not feel free even in an environment where a just culture is valued.
References
Mayer, C. & Cronin, D. (2008). Organizational accountability in a just culture. Urologic Nursing, 28(6), p. 427-430.
