Wk 3: Promoting Patient Safety and Just Culture Flashcards
Just culture
movement away from blame environment to one of personal and professional accountability. Instead of punative, RCA and furthering education about error is new for HC.
Near misses
Just culture promotes discussing errors and near misses so they can be part of a solution to prevent future mistakes.
IOMs 5 competencies
- Patient Centered Care
- Work on Interprofessional Teamwork
- Employ EBP
- Apply QI
- Utilize Informatics
Agencies for Pt Safety and Just Culture
IOM report, ANA, AHRQ, AACN, NDNQI, QSEN
3 Behaviors
Human error- unintentional
At-Risk behavior- short cut- need to re-educate
Reskless Behavior- understand risk can occur, conscious choice, blame and discipline worthy
When error occurs
RCA
establish learning environment
reduction of at-risk behaviors
Geriatric Just culture
falls- majority cause of morbidity, 25% cause serious injury
med errors