Safety culture is the ways in which safety is managed in the
workplace, and reflects the attitudes, beliefs, perceptions and
values that employees share in relation to safety. In other words
“the way we do safety around here.”
Just this week, concurrent with the 2011 AORN Congress, AORN
released an article that was really quite interesting. The
article, entitled “The Silent Treatment,” discusses the
shortcomings of checklists, bundles and Safety Tools. They’re
hardly the first to address this concern. While many have been
insisting on culture change as an essential element to
implementing these very effective Tools, the most recent
authoritative voice may be that of Peter Pronovost, MD, PhD.
Problems at the point of care frequently arise. How the
front-line staff addresses those problems affects the capability
for organizational learning. The most common staff response to a
problem is one that prevents learning.
Clinical peer review has yet to fulfill its obligation to enhance
quality and patient safety. Most hospitals still rely on an
outmoded and dysfunctional quality-assurance model for peer
review (see CHPSO Patient Safety News July 2010). An emerging
QI Model is far
superior. You can quickly assess your own program with the
evidence-based, online Peer
Review Program Self-Evaluation Tool.
The final results of the 2009 American College of Physician
Executives’ Peer Review Outcomes Study, just released online by
the American Journal of Medical Quality, show that when doctors
do clinical peer review using new methods, hospitalized patients
benefit from safer care.1
The purpose of this article is to describe the influence of
Just Culture training on leaders’ perceptions of their patient
safety culture and to explore how those perceptions
align with staff across the nation.
This presentation at the 2010 National Council of State Boards of
Nursing (NCSBN) Scientific Symposium provided an overview of
“just culture” and discussed the implementation and impact of the
Missouri Just Culture Collaborative.
To collect productive investigative data, we must promote a
culture in which employees are willing to come forward in the
interests of system safety. Yet, no one can afford to offer a
“blame-free” system in which all conduct has impunity — society
rightly requires that some actions warrant disciplinary or
enforcement action. It is the balancing of the need to learn from
our mistakes, and the need to take disciplinary action, that
motivates adoption of a just culture.
Attached is a brief yes/no questionnaire for senior managers
assessing the organization’s commitment to a just culture.
This report is designed as an aid for health care executives,
labor attorneys, labor leaders, and human resource specialists
who must struggle with what to do, in the disciplinary context,
with an erring health care professional. It is a guide for more
thoroughly understanding the problems posed by current
disciplinary approaches, and to possible changes in your current
disciplinary policies as you contemplate implementation of a new
reporting and investigation system.
In many situations, the correct action promoting a just culture
is not intuitive. It is human nature to become upset and seek
“justice” when a patient is severely injured, yet our response to
events and near misses should not be based upon actual outcomes,
rather upon the potential for patient harm.
Incident decision tree adapted from the UK National Health
Service’s National Patient Safety Agency (NPSA), and a Guide to
Use (from the 2003 version). The National Health Service (NHS)
also issued Guidelines for Action Following Patient Safety
Incidents. This algorithm focuses on identifying whether an
individual was at least partially culpable for the event. The
following is a brief summary of the decision tree, from the NPSA
web site.
Allen Frankel and Michael Leonard propose a combination of the two models, with some simple questions to help investigators walk through the possibilities:
