JUST CULTURE DECEMBER 12,2012
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1 JUST CULTURE DECEMBER 12,2012 P R E S E N T E D B Y : K A T H Y F O W L E R : Q I P R O J E C T M A N A G E R M A R G R E T T U C K E R : W O U N D C A R E N U R S E P A U L L E V Y : N U R S E E D U C A T O R
2 WHAT IS JUST CULTURE? A defined set of values, beliefs, and norms about what is important and how to behave What behavioral choices and decisions are appropriate related to occurrences of human error or near misses. Open reporting and participation in prevention and improvement is encouraged There is recognition that errors are often system failures (not personal failures) Focus on understanding the root of the problem allows for learning, process improvement, and changes to design strategies and systems to promote prevention.
3 WHAT JUST CULTURE IS NOT Just Culture is not a blame-free culture. Rather, it is a culture that requires full disclosure of mistakes, errors, near misses, patient safety concerns, and sentinel events in order to facilitate learning from such occurrences and identifying opportunities for process and system improvement.
4 ACCOUNTABILITY A Just Culture is also a culture of accountability Individuals will be held responsible for their actions within the context of the system in which they occurred Accountability may involve system improvement Accountability may involve individual consoling, coaching, education, counseling, or corrective action.
5 BALANCE A Just Culture balances the need to learn from mistakes with the need to take corrective action against an individual if the individual s conduct warrants such action. Individuals are Blamed for all Mistakes Blame Free-No one is held accountable A Just Culture is a middle ground between a blame-free culture with no personal accountability and a culture in which individuals are blamed for all mistakes
6 PATIENT SCENARIO Patient was admitted 11/26/12 for compression fractures Patient was ordered a TLSO Brace application of the device on 11/27 at 3:45 pm TLSO: Thoracolumbosacral orthosis. This is one of two main types of braces used to correct the lateral (sideways) curve of the spine in scoliosis. Patients with osteoporotic compression fractures are often treated with TLSO bracing The TLSO is an underarm brace, which means that it fits under the arm and around the rib cage, lower back, and hips Patient brace was applied on 11/27 at 3:45 pm and kept in place for approximately 18 hrs. 11/28/2012 TX Developed Pressures to back and buttock ET nurse consult
7 TLSO BRACE : THORACOLUMBOSACRAL ORTHOSIS.
8
9 ADMISSION ASSESSMENT MISC. NOTE
10 ADMITTING NURSE
11 FIRST NURSE CARING FOR THE PATIENT
12 SKIN POLICY HS-NA0415 *
13 NURSING SKIN ASSESSMENT Brace applied 3:45 pm
14 DEL LA TORRE ORTHOTICS Brochure given to every patient at the delivery of a TLSO. In the case of PJ our clinician followed the procedure for delivery and application of the device on 11/27 at 3:45 pm and opted for raising the head of PJ bed up to check the fit of the device. PJ specifically requested that she be allowed to keep the TLSO on so she could sit up. This was done by the clinician. At the time of the application the clinician did note a number of red places on the back of the patient. They were not blisters but they were noticeably red. Please note the excerpt from the dictation below noting this.
15 DEL LA TORRE ORTHOTICS Dictation excerpt: While I was there log rolling pt on to her side I did notice that she had a few circular areas of irritation around the midpart of her back ranging from just below her scapula to around the area of her waist red irritated area. This did seem to be approximately 1/2-3/4" in diameter. There was no liquid or any type of fluid coming from these areas. I also after sitting pt up in her bed she did state that she felt more supportive with the brace on and did want to continue sitting with the head of her bed up past 45 degree angle therefore she asked if the brace could be left on.
16 DOCUMENTATION OF BRACE
17 ET NURSE DOCUMENTATION
18 ET NURSE WOUND DOCUMENTATION PAGE 1
19 WHAT DID WE LEARN? Skin assessment documentation Brace application process Knowledge/Understanding Policy Was the physician orders complete? Legal implications of documentation and providing care to the patient that is within the standard of care and Do we know Del La Torres standard? Do we have a policy or standard of care? Patient Harm 9 HAPU s Nursing Resources/ support Nurses Duty to find out the information Critical thinking :What is the nursing practice for caring for a patien with unfamiliar equipment/medication etc
20 JUST CULTURE MEANS ACCOUNTABILITY FOR OUR BEHAVIORS Human Error Inadvertent Action:Slip,Lapse, Mistake At-Risk behavior A Choice: Risk not recognized or believed justified Reckless Behavior Conscious disregard of unreasonable risk Manage through changes in: Processes Procedures Training design Manage through: Removing incentives for at risk behaviors Creating incentives for healthy behaviors Increasing situational awareness Manage through: Remedial action Corrective action CONSOLE COACH CORRECTIVE
21 IMPORTANT TAKE AWAYS: Follow the nursing process The five steps of the nursing process are recognized as a universal approach to nursing practice. A failure on your part during any of these steps can lead to trouble: NURSING ASSESSMENT-COLLECTING DATA REGARDING YOUR PATIENT'S SIGNS AND SYMPTOMS NURSING DIAGNOSIS-APPROPRIATELY IDENTIFYING THE PATIENT'S PROBLEMS PLANNING-SETTING GOALS OF CARE AND DESIRED OUTCOMES AND IDENTIFYING APPROPRIATE NURSING ACTIONS IMPLEMENTATION-PERFORMING THE NURSING ACTIONS IDENTIFIED IN PLANNING EVALUATION-DETERMINING IF THE GOALS WERE MET AND THE OUTCOMES WERE ACHIEVED AND APPROPRIATELY REVISING THE CARE PLAN BASED ON THE PATIENT'S RESPONSE.
22 As a nurse, you have a duty to make sure you've received adequate training on the equipment you use to provide patient care. You must understand the equipment's intended use, know how to operate it properly, and follow policies and procedures for using it if they exist. Never try guessing how to use equipment. UTILIZE YOUR RESOURCES SEEK CLARIFICATION
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Mary Baum President & CEO BA&T September 18, 2015 Objective Why patient safety is so difficult to solve? The problem remains Advances in clinical workflow A collaborative approach Metrics matter Just start.