Just Culture Assignment Discussion Paper

Errors are not unique where humans are involved, and the occurrence of errors can result in accidents. Within the health care industry, the occurrence of errors and accidents is not uncommon and they can result in mortality, morbidity and other adverse outcomes. The typical approach to addressing the occurrence of errors and accidents is seek them (errors and accidents) out and identify the persons responsible for punishment. This punitive model is faulted for failing to solve the problem. Medical personnel provide care within medical systems that are designed by a medical organization. This implies that although most cases involve an individual being at fault, there are many cases where the system contributes to the fault or when the system is solely responsible for the fault. In punishing the individual involved in the fault, the punitive model fails to change the failing system such that the problem continues to be perpetuated rather than being solved (American Nurses Association, 2010) Just Culture Assignment Discussion Paper.

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All health care systems are inherently designed with the obligation to collect data that contributes to productive investigations as the data can be analyzed and acted upon to support and improve patient care. This process is only possible when the persons involved in the system (particularly the medical personnel providing care) maintain continuous surveillance while remaining mindful and vigilant. Similarly, these persons must belief that they have an obligation to report these faults, failures and errors. This is best achieved when they are not blamed for the errors as then they would be more vigilant in reporting all failures and the associated details. On the other hand, the health care industry cannot afford to implement a blame-free culture as that could cause the medical personnel to be less vigilant in completing their professional responsibilities. In essence, the more serious and negligent errors would warrant disciplinary actions. This indicates that there is a need for a balance between a blameless culture and a punishment culture, which would allow all errors to be reported and appropriate corrective actions undertaken even as disciplinary actions are undertaken against the errors that warrant such action (Dekker, 2018) Just Culture Assignment Discussion Paper.

It is this awareness that creates the need for a just culture that balances the need for honest and open reporting environment with accountability. While a health care organization has a responsibility and duty to its employees, they must all be held responsible for their choices in the practice environment, particular the quality of their decisions and actions. In adopting a just culture, a shift is made from focusing on the outcomes and errors to designing good systems and managing the employees’ behavioral choices. In essence, a just culture is value-based and insists on shared accountability while ensuring that no practitioner is held accountable for a mistake that originates from a system that the individual cannot control (Leape, 2021).

This shows that a just culture goes beyond ensuring that medical personnel feel free to report errors as it fosters mindfulness among them. This shift towards mindfulness is seen in five key areas. First, it engenders the ability to flatten and alter the organizational hierarchy to fit a specific situation. Second, it engenders the ability to concentrate on specific tasks while having a sense of the mission and vision. Third, it engenders the ability to adapt when there is an unexpected occurrence. Fourth, it ensures that expertise is recognized regardless of status and rank. Fifth, it ensures that employees are constantly concerns about the possibility of facing failure (Albert et al., 2022). In this respect, a just culture engenders mindfulness within an organization so that it moves beyond occurrences and events with the organization gaining the ability to continually learn, adjust and redesign the system for safety while managing behavioral choices hereby supporting patient care Just Culture Assignment Discussion Paper.

References

Albert, N. M., Pappas, S., Porter-O’Grady, T., & Malloch, K. (2022). Quantum Leadership: Creating Sustainable Value in Health Care: Creating Sustainable Value in Health Care (6th ed.). Jones & Bartlett Learning, LLC.

American Nurses Association (2010). Just Culture: Position Statement. https://www.nursingworld.org/~4afe07/globalassets/practiceandpolicy/health-and-safety/just_culture.pdf

Dekker, S. (2018). Just Culture: Restoring Trust and Accountability in Your Organization (3rd ed.). CRC Press.

Leape, L. L. (2021). Making Healthcare Safe: The Story of the Patient Safety Movement. Springer Nature.

As an alternative to a punitive system, application of the Just Culture model, which has been widely used in the aviation industry, seeks to create an environment that encourages individuals to report mistakes so that the precursors to errors can be better understood in order to fix the system issues. —American Nurses Association, 2010 Mistakes happen. There is no way to avoid all mistakes, so how might your practice change if the reporting of mistakes was welcomed, versus penalized? How might this lead to a better understanding of quality improvement and safety needs? How might patient safety be improved? For this Discussion, consider the role of just culture in your organization. Reflect on your experience with just culture and consider how this model might support patient care. Reference: American Nurses Association. (2010). Just culture [Position statement]Just Culture Assignment Discussion Paper. https://www.nursingworld.org/~4afe07/globalassets/practiceandpolicy/health-and-safety/just_culture.pdf To Prepare: Review the Learning Resources for this week, and reflect on your experiences with just culture. Consider how just culture connects to quality and safety. What is the role of the DNP-prepared nurse in promoting just culture in organizations and nursing practice? By Day 4 of Week 1 Post an explanation of whether your organization uses a just culture. Then, explain how this might impact quality and safety for your healthcare organization, and why. What is the DNP-prepared nurse’s role in supporting a just culture environment in a healthcare organization? Be specific and provide examples Just Culture Assignment Discussion Paper