In 2017, a patient died after a medication error at Vanderbilt University Medical Center in the United States. We extend our sympathies to the family who suffered this tragic loss. Many healthcare professionals watched the case carefully, as the nurse who administered the wrong medication was criminally charged.
Criminalization of a medical error diverts attention from important aspects of patient safety that support our health systems to learn and improve.
No one is more equipped to make improvements to patient safety than healthcare workers, and the patients and families they serve. Healthcare workers are at the frontline delivering and witnessing care. As a result, they are in a unique position to identify potential and actual errors. They rely on safe venues to discuss unsafe situations, and require a healthcare system that is committed to acting on their findings. When we focus on individual blame and punishment, this can create a culture of fear that shuts down transparency and fosters an environment where healthcare workers no longer feel safe to voluntarily report potential and actual errors. This ultimately makes our health systems less safe.
A just culture
Organizations with a just culture see errors as opportunities to learn and to improve the healthcare system. Healthcare workers in a just culture trust their organization and feel that staff are treated fairly when they are involved in a patient safety event, including when they make an error. Reports of errors and patient safety hazards are important sources of information about weaknesses in the system, and are used to improve patient safety.
It is vital to promoting and improving patient safety that, as healthcare leaders, we ensure our organizations have a consistent, systematic and fair approach for gathering, organizing, and interpreting information about patient safety incidents and the actions taken by those involved. This begins with a thorough assessment of an incident using a systems-based approach that supports looking beyond the contribution of the individuals involved, and considers how complex interacting elements can influence care.
Tools such as the Just Individual Assessment (JIA) support a just culture and can be used to assess individual accountability within the context of the situation, including understanding contributing system factors.
The Health Quality Council of Alberta has created recommendations on what patients and families, healthcare workers, and organizations can do to foster a just culture. Now, more than ever, we need to commit to a just culture and we invite you to join us. Please check out our just culture website and the many resources available on this important topic.
Charlene McBrien-Morrison, Chief Executive Officer
HQCA Matters is published intermittently and presents HQCA representative perspectives on topics or issues relevant to healthcare in Alberta.