Caf A Liz Forsberg Clinical Pharmacist Kathy Fowler QI Project - - PowerPoint PPT Presentation
November 14 2012 12-12:30pm Caf A Liz Forsberg Clinical Pharmacist Kathy Fowler QI Project Manager A Just Culture balances the need to learn from mistakes with the need to take corrective action against an individual if the
Blame Free-No one is held accountable Individuals are Blamed for all Mistakes
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
Inadvertent Action:Slip,Lapse, Mistake Manage through changes in: Processes Procedures Training design
A Choice: Risk not recognized or believed justified Manage through: Removing incentives for at risk behaviors Creating incentives for healthy behaviors Increasing situational awareness
Conscious disregard of unreasonable risk Manage through: Remedial action Corrective action
CONSOLE COACH CORRECTIVE
EMERGENCY DEPARTMENT
given in an
emergency
situation ???
NURSING
knowledge deficit
administering Lantus
who spoke to the physician the right person with the information
PHYSICIAN/RESIDENT
record default times to that evening when
from patient med reconciliation
this issue to Physician Med PHARMACY
for “One time dose” falls to the bottom of PHARM NET page
verifying admission medication
the order to be appropriate from the patient home meds list PATIENT
Use the Unsafe Acts Algorithm A mechanism to assess individual versus system accountability has been developed by James Reason in his “Unsafe Acts” algorithm (Reason 1997). Did the employee intend to cause harm? Did the employee come to work impaired? Did the employee knowingly and unreasonably increase risk? Would another similarly trained and skilled employee in the same situation act in a similar manner (Reason's substitution test)? If the first three answers are “No” and the last “Yes” the origin of the unsafe act lies in the organization, not the individual.