From a blame culture to a just culture in health care

2009 ◽  
Vol 34 (4) ◽  
pp. 312-322 ◽  
Author(s):  
Naresh Khatri ◽  
Gordon D. Brown ◽  
Lanis L. Hicks
Keyword(s):  
Health Care ◽  
Just Culture ◽  
Blame Culture

scholarly journals Inconvenient truths in suicide prevention: Why a Restorative Just Culture should be implemented alongside a Zero Suicide Framework

2020 ◽  
Vol 54 (6) ◽  
pp. 571-581 ◽  
Author(s):  
Kathryn Turner ◽  
Nicolas JC Stapelberg ◽  
Jerneja Sveticic ◽  
Sidney WA Dekker
Keyword(s):  
Health Care ◽  
Suicide Prevention ◽  
Cultural Change ◽  
Successful Implementation ◽  
Just Culture ◽  
Healthcare Settings ◽  
Prevailing Paradigm ◽  
Specialist Services ◽  
Erroneous Belief ◽  
Outcome Biases

Objective: The prevailing paradigm in suicide prevention continues to contribute to the nihilism regarding the ability to prevent suicides in healthcare settings and a sense of blame following adverse incidents. In this paper, these issues are discussed through the lens of clinicians’ experiences as second victims following a loss of a consumer to suicide, and the lens of health care organisations. Method: We discuss challenges related to the fallacy of risk prediction (erroneous belief that risk screening can be used to predict risk or allocate resources), and incident reviews that maintain a retrospective linear focus on errors and are highly influenced by hindsight and outcome biases. Results: An argument that a Restorative Just Culture should be implemented alongside a Zero Suicide Framework is developed. Conclusions: The current use of algorithms to determine culpability following adverse incidents, and a linear approach to learning ignores the complexity of the healthcare settings and can have devastating effects on staff and the broader healthcare community. These issues represent ‘inconvenient truths’ that must be identified, reconciled and integrated into our future pathways towards reducing suicides in health care. The introduction of Zero Suicide Framework can support the much-needed transition from relying on a retrospective focus on errors (Safety I) to a more prospective focus which acknowledges the complexities of healthcare (Safety II), when based on the Restorative Just Culture principles. Restorative Just Culture replaces backward-looking accountability with a focus on the hurts, needs and obligations of all who are affected by the event. In this paper, we argue that the implementation of Zero Suicide Framework may be compromised if not supported by a substantial workplace cultural change. The process of responding to critical incidents implemented at the Gold Coast Mental Health and Specialist Services is provided as an example of a successful implementation of Restorative Just Culture–based principles that has achieved a culture change required to support learning, improving and healing for our consumers, their families, our staff and broader communities.

scholarly journals Eliciting the Functional Processes of Apologizing for Errors in Health Care

2017 ◽  
Vol 4 ◽  
pp. 233339361769668 ◽  
Author(s):  
Marie M. Prothero ◽  
Janice M. Morse
Keyword(s):  
Health Care ◽  
Essential Elements ◽  
Concept Development ◽  
Physician Patient Relationship ◽  
Patient Centered ◽  
Data Synthesis ◽  
Just Culture ◽  
Centered Care ◽  
Physician Patient ◽  
Response Policy

This article has been awarded GQNR’s Best Paper Award for the 2017 Volume The purpose of this article was to analyze the concept development of apology in the context of errors in health care, the administrative response, policy and format/process of the subsequent apology. Using pragmatic utility and a systematic review of the literature, 29 articles and one book provided attributes involved in apologizing. Analytic questions were developed to guide the data synthesis and types of apologies used in different circumstances identified. The antecedents of apologizing, and the attributes and outcomes were identified. A model was constructed illustrating the components of a complete apology, other types of apologies, and ramifications/outcomes of each. Clinical implications of developing formal policies for correcting medical errors through apologies are recommended. Defining the essential elements of apology is the first step in establishing a just culture in health care. Respect for patient-centered care reduces the retaliate consequences following an error, and may even restore the physician patient relationship.

scholarly journals Just Culture Is Not “Just” Culture—It’s Shifting Mindset

2020 ◽  
Vol 185 (Supplement_3) ◽  
pp. 52-57
Author(s):  
Cynthia Foslien-Nash ◽  
Brady Reed
Keyword(s):  
Health Care ◽  
High Reliability ◽  
Improve Patient Care ◽  
Veterans Administration ◽  
Veterans Health ◽  
Health Administration ◽  
Quality Outcomes ◽  
Just Culture ◽  
Wrong Thing ◽  
Texas Health

ABSTRACT Health care and the Veterans Health Administration have adopted many initiatives to improve patient care, including efforts to create a “Just Culture” environment for patient safety and quality outcomes. Despite significant resources and efforts on these initiatives and some temporary improvements, we continue to struggle to make significant and sustainable improvements. At the Veterans Administration North Texas Health Care System, we see that our efforts have addressed the wrong thing. By focusing our efforts to shift the underlying mindset that drives behavior, we expect to create the foundation that will help us truly achieve a High Reliability and Just Culture organization that provides the care and outcomes our patients and staff deserve.

The Second Victim Phenomenon

2017 ◽  
pp. 197-222
Author(s):  
Paraskevi K. Skourti ◽  
Andreas Pavlakis
Keyword(s):  
Health Care ◽  
Adverse Event ◽  
Health Professional ◽  
Healthcare System ◽  
Medical Error ◽  
Health Professionals ◽  
Professional Life ◽  
Serious Adverse Event ◽  
Second Victim ◽  
Blame Culture

Medical error happens when an action within the medical field is not fulfilled as planned, or the plan is performed incorrectly. Patient and family are the first victim of an adverse event. The damage in a patient's health, leads in a distressing situation not only for the patient, but also for the clinician who is responsible for this outcome. The term “second victim” refers to the trauma that a health professional sustains due to a serious adverse event in the healthcare system. After a medical error the caregivers are experiencing the aftermath in their personal and professional life. They feel isolated and abandoned, and some of them are coming up against the law with penal and disciplinary ramifications as a consequence of the blame culture in the health care system. Some health professionals experienced the consequences of an unfortunate incident even if it did not lead in harm to the patient's health.

Apprendere dagli errori per migliorare sicurezza e affidabilitŕ organizzativa: il contributo della sociologia dell'organizzazione

2009 ◽  
pp. 96-110
Author(s):  
Maurizio Catino
Keyword(s):  
Organizational Learning ◽  
Social Processes ◽  
Accident Analysis ◽  
Main Attention ◽  
Organizational Research ◽  
Just Culture ◽  
Safety And Reliability ◽  
Blame Culture ◽  
The Individual ◽  
Organizational Logic

- The objective of this article is to examine which role the theory and sociology of organization might have in the accident analysis of organizations for the improvement of safety and reliability. The possible role for organizational research on accidents in organizations. The two main aims are: the analysis of two different logics of inquiry in case of accidents - the individual blame logic vs the functional-organizational logic-; the evaluation of the possible role and the practical difficulties in the implementation of an organizational approach if errors and organizational accidents occur. Main attention will focus on organizational research direct to have influence on social processes and conditions of extra-academic effect.Key words: organizational learning, organizational errors, blame culture, just culture, safety, organizational reliability

Malpractice & Negligence: Cal. Supreme Court Clarifies Negligence Provisions under State’s Elder Abuse Act

1999 ◽  
Vol 27 (2) ◽  
pp. 203-203
Author(s):  
Kendra Carlson
Keyword(s):  
Health Care ◽  
Supreme Court ◽  
Health Care Providers ◽  
Elder Abuse ◽  
Skilled Nursing Facility ◽  
Pressure Sores ◽  
Care Providers ◽  
Nursing Facility ◽  
Skilled Nursing ◽  
The Supreme Court

The Supreme Court of California held, in Delaney v. Baker, 82 Cal. Rptr. 2d 610 (1999), that the heightened remedies available under the Elder Abuse Act (Act), Cal. Welf. & Inst. Code, §§ 15657,15657.2 (West 1998), apply to health care providers who engage in reckless neglect of an elder adult. The court interpreted two sections of the Act: (1) section 15657, which provides for enhanced remedies for reckless neglect; and (2) section 15657.2, which limits recovery for actions based on “professional negligence.” The court held that reckless neglect is distinct from professional negligence and therefore the restrictions on remedies against health care providers for professional negligence are inapplicable.Kay Delaney sued Meadowood, a skilled nursing facility (SNF), after a resident, her mother, died. Evidence at trial indicated that Rose Wallien, the decedent, was left lying in her own urine and feces for extended periods of time and had stage I11 and IV pressure sores on her ankles, feet, and buttocks at the time of her death.

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