Caf A Liz Forsberg Clinical Pharmacist Kathy Fowler QI Project - PowerPoint PPT Presentation

November 14 2012 12-12:30pm Café 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 individual’s conduct warrants such action. Individuals are Blame Free-No one is Blamed for all held accountable 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

Just Culture Means Accountability for Our Behaviors Reckless Human At-Risk Error behavior Behavior Inadvertent A Choice: Risk not Conscious disregard of Action:Slip,Lapse, recognized or unreasonable risk Mistake believed justified Manage through Manage through: changes in: Removing incentives Processes Manage through: for at risk behaviors Procedures Remedial action Creating incentives Training for healthy behaviors Corrective action design Increasing situational awareness CORRECTIVE CONSOLE COACH

EMERGENCY NURSING PHYSICIAN/RESIDENT PHARMACY DEPARTMENT • Identified • Medication order knowledge deficit • Lantus not usually • Unaware of the E- for “One time of the nurse given in an record default dose” falls to the administering emergency times to that bottom of PHARM Lantus situation ??? evening when NET page ordering Lantus • Pharmacist • Is the Charge nurse from patient med PATIENT verifying who spoke to the reconciliation admission physician the right • Communicating medication person with the this issue to orders identified information Physician Med the order to be appropriate from the patient home meds list

All Managers will review events in the same manner 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.