131 Background: UPMC CancerCenter is a large outpatient medical oncology network of 25 locations, located within a 200 mile radius of Pittsburgh, PA. The Cancer Center administers approximately 118,000 treatments and 38,000 injections per year by 200 oncology nurses. Staff members have been strongly encouraged for years to report not only medication errors but also near misses. Despite the continual encouragement it was suspected that the actual number of reported medication errors and near misses was frequently underreported. Methods: In 2012 a Safety Culture Survey comprised of 43 questions was administered to all clinical staff in order to evaluate the comfort level of the staff in speaking up about medication safety issues. Cancer Center leadership wanted to convert from a ‘no blame’ response to errors to a ‘Just Culture’ environment that includes not only a robust accountability model but a model for addressing system and behavioral risks both before and after events occur. This survey was again repeated in 2014. At the conclusion of each survey period nursing leaders conducted on site in-services at every Cancer Center location. Individual site results along with Cancer Center aggregate results were reviewed with all participants. Participants were challenged to identify action items that could contribute to improving patient safety. Results: The results indicated a decrease in the number of respondents who reported feeling fearful of reporting in in 2012 (33%) compared to 2014 (28%). The number of reported near misses increased by 181% while actual error reported increased by 45% from 2012 to 2014. Conclusions: Staff quickly realized that should an error occur they would be treated fairly when they report medication errors. The staff also realized the positive impact that reporting has on patient safety. The conversion to a “Just Culture’ environment significantly increased the number of medication errors reported as a result of open communication and the implementation of a well-established system of accountability.
A Just Culture Approach to Managing Medication Errors
