JUST CULTURE FEBRUARY 20, 2013 KAREN ZANIN RN CNOR

JUST CULTURE FEBRUARY 20, 2013 KAREN ZANIN RN CNOR

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

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.

Just Culture Means Accountability for Our Behaviors Human Error At-Risk behavior Reckless Behavior Inadvertent Action:Slip,Lapse, Mistake A Choice: Risk not recognized or believed justified 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

Event Discussion OR Charge Nurse is notified by the pre-op education nurses of patients on the next day s surgery schedule with latex allergies. The latex allergy is then entered by the OR Charge Nurse into the Surginet OR schedule which then provides documentation of the allergy in the EHR and on the electronic and printed OR Schedules. Patient arrived 12-7-12 for Total Knee Replacement surgery. OR Circulating Nurse had pre-op visit with patient and confirmed latex allergy. OR Staff prepared for surgery using latex free supplies. Surgeon requested placement of Foley Catheter for surgical procedure. Catheter sent in Patient Supply Cart (case cart) contained Latex which was recognized by the Operating Room nurse as containing latex. RN obtained another Foley Catheter from supply area, thinking that it was latex free. Patient was catheterized with indwelling (Foley) latex catheter. Latex catheter placement was discovered in PACU where it was removed. Surgeon was notified and Foley catheter was removed; no additional urinary catheterization needed.

SPD NURSING Lack of communication to SPD staff of latex allergies Newer nurse unfamiliar with supply storage area Nurse felt pressured to complete catheterization quickly Latex foley catheter placed in latex allergy patient Close proximity of latex and latex free catheters Supply requisition prints prior to knowledge of latex allergy IS ISSUE Storage shelves not labeled STORAGE

Supply requisition

Latex catheter kits Latex free catheter kits

Identified Root Causes Supply requisition is sent to supply department prior to knowledge of latex allergy. Supply department unaware of patient s latex allergy. Latex supplies pulled for surgery. Storage shelf not labeled. Nurse on orientation unfamiliar with storage, and acting in haste. PATIENT

Outcomes Staff encouraged to call for assistance in similar situations (feeling rushed or overwhelmed). Investigating possibility of SPD and OR Departments stocking only Latex Free catheters. Storage shelf is now labeled to indicate latex free catheters. Additional communication to the SPD staff regarding patients with latex allergies.

Just Culture Means Accountability for Our Behaviors Human Error At-Risk behavior Reckless Behavior Inadvertent Action:Slip,Lapse, Mistake A Choice: Risk not recognized or believed justified 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