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Knowing I’m an RN, a couple of people have asked me what I think about the Radonda Vaught verdict. If you’re unaware of the case, a jury recently found Ms. Vaught (also an RN) guilty of criminally negligent homicide in the death of a patient after she made a medication error.
I’ve heard a few different versions of what happened, so I didn’t know what to think. Fortunately, I found an excellent summary of the facts in an article by Kati Klieber, RN. Ms. Klieber is a master’s prepared ICU nurse with a passion for mentoring new nurses. I hope you’ll read her article before you make any judgments.
As I read about the Radonda Vaught case, I came upon a term that was new to me: Just Culture. Have you ever heard of this concept? Today I want to share its main points because I believe Just Culture is useful in all areas of healthcare, including nursing homes.
What is Just Culture?
I like this definition from Professor Sir Norman Williams: “A just culture considers wider systemic issues where things go wrong, enabling professionals and those operating the system to learn without fear of retribution.”
Just Culture recognizes that humans make mistakes. However, these mistakes are rarely the result of one person deliberately acting in a bad way. More often, problems within the organization’s systems contribute to the error.
A litany of factors can lead to a mistake. For example:
- Lack of proper training
- Malfunctioning or outdated equipment
- Poorly communicated instructions
- Understaffing
- Inconsistent policies
Why is Just Culture so important?
In many healthcare organizations, we focus on finding out who is to blame for an error and then we punish that person. This response often makes employees hesitant to admit their mistakes for fear of the consequences. It also overlooks potential root causes and increases the risk of someone else making the same mistake.
Rather than making people feel shamed, Just Culture promotes a sense of trust and respect. This leads to better morale among employees and increased resident safety. It also increases the chance of catching a minor error before it causes more significant harm.
Does Just Culture ignore personal accountability?
Some people express concern that Just Culture focuses so much on systemic problems that it releases employees from personal accountability. That’s not the case.
In rare situations, it might be determined that an error directly resulted from an employee being reckless or uncaring. Then the supervisor must start disciplinary action according to the organization’s protocol.
Where to go from here
The process of how to develop Just Culture in your nursing home goes way beyond the scope of this blog post. Fortunately, Just Culture has been around for decades in other professions, so you can find lots of excellent information online.
I hope you’ll learn more about Just Culture and then bring it to the attention of your co-workers and supervisors. You’ll help create a better environment for employees and for residents.
Does your nursing home practice Just Culture? I would love to see you add your thoughts in the comment section.
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