Innovations-Magazine-May-2023 - 9

Under pressure of these combined challenges, stakeholders
are searching for new models to improve safety and workplace
conditions. Many experts believe that following a " just culture "
approach to reporting and responding to mistakes and potential
safety issues is one of the most effective methods. But what exactly
does a just culture entail, and how can it help improve patient safety
and working conditions?
Understanding a Just Culture
A just culture approach is often presented as an alternative to a
" blame culture. " The idea is to create a workplace culture that
encourages transparency and learning from mistakes, rather than
taking disciplinary action in the event of errors or near misses. This
approach recognizes that errors can occur in any system and that
individuals should not bear the blame for honest mistakes. Instead,
the culture should focus on analyzing where the system failed and
correcting that potential vulnerability to prevent future mistakes.
In health care, a just culture is used to promote patient safety by
encouraging providers to report errors and potential safety issues.
Unfortunately, not all cases have followed this just culture
approach. Medical error, including those caused by medication
mistakes, is estimated to be the third leading cause of death in the
United States. A recent high-profile example illustrates how serious
some mistakes can be and the magnitude of consequences for an
individual in the disciplinary model.
Medication Error Leads to Patient Death,
Controversial Prosecution
In 2017, a patient recovering from a brain injury was being prepared
for discharge from a hospital in Tennessee after her condition showed
signs of improvement. The patient was prescribed a sedative called
Versed® (midazolam), intended to calm her before undergoing a
medical scan procedure. Using an automated dispensing cabinet, the
nurse assigned to administer the drug instead withdrew and delivered
vecuronium, a powerful paralytic. The patient died of respiratory
arrest a short time later.
The nurse was eventually arrested, charged, and prosecuted for
the death of the patient. In 2022, she was convicted of gross neglect
of an impaired adult and negligent homicide. She was sentenced to
three years of criminal probation. The case has proven controversial.
Those in favor of criminal charges, including prosecutors, have
argued that the nurse ignored several warnings that could have
prevented the error and ultimately overrode the automated dispensing
cabinet system. This, they argued, demonstrated reckless behavior,
which played a significant factor in her conviction. Other experts, such
as the Institute for Safe Medication Practices (ISMP), have expressed
support for the nurse and concern that this prosecution and conviction
run counter to just culture. They also argue that the nurse's case is an
example of severity bias, where blame and punishment are seen as more
necessary because the outcome involved a patient death. Advocates for
just culture argue that this kind of bias in health care workplaces does
not improve patient safety.
" [T]he question within a Just Culture is not whether harm
occurred, but whether the individual consciously disregarded what he
or she knew to be a substantial and unjustifiable risk, " ISMP wrote
on its website in support of the nurse.
MAY 2023 | 7
Innovations-Magazine-May-2023

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