JUST CULTURE

JANUARY 2013

Accountability

A “Just Culture” is also a culture of

accountability

Individuals will be held responsible for

their actions within the context of the

system in which they occurred

Accountability may involve system

improvement

Accountability may involve individual

consoling, coaching, education,

counseling, or corrective action.

What Just Culture IS NOT

“Just Culture” is not a “blame-free”

culture. Rather, it is a culture that requires full disclosure of

mistakes, errors, near misses, patient safety concerns,

and sentinel events in order to facilitate learning from such

occurrences and identifying opportunities for process and

system improvement.

Balance 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.

Blame Free-No one is

held accountable

Individuals are

Blamed for all

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

Event Description

• Patient admitted through ED

• Scaly, red rash is documented

in nursing assessment

• It was reported to IC that

bedbugs were seen in patient

belongings at this time

• Not documented in medical chart

• Family notified staff that there

was a bedbug problem at home

• Not documented in medical chart

• Patient in contact isolation on

admission to 3B to room 346

Event Description, cont.

• Infection Control instructs that the patients with bedbugs (includes home infestation), lice, or scabies not be moved during stay unless a higher level of care needed or they have completed a course of treatment.

• This statement was not in policy at time of event

• No documentation of this communication

• The next day, patient was moved to 363

• Infection Control alerted to transfer by housekeeping

• IC immediately reinforced to unit staff and Bed Flow Coordinator that patient should not be transferred unless a higher level of care was needed

• Original room was blocked until contracted pest control company completed evaluation/application.

HANDOFF

Event Description, cont.

• Patient moved to 4AM two days later • Two rooms on 3B now blocked until cleared by pest control

• Again, Infection Control alerted to transfer by housekeeping

• The next day, 4AM set to close and patient to be transferred off unit • Would result in 4 blocked rooms if transferred (Two on 3B, one on

4AM, and one on a med-surg unit to which the pt. was transferred)

• IC suggests patient is transferred back to one of the 3B blocked rooms to prevent yet another room from pest control/blocking

• Patient was discharged from 4AM instead of being sent to a fourth room

HANDOFF

HANDOFF

Initial Assessment in ED – 10/29

H&P – 10/30

Progress Note – 10/31

MD noted bedbugs, but patient was still transferred to 4AM, which frequently

closes. If possible, patients with skin infestations should not be transferred to

units that can close. (In this case, patient should not have been transferred at all

as a higher level of care was not needed.)

Bedbugs – Life Cycle

Bed Bug Bites

• Often in clusters

Bed Bugs

• Infestations occur in mattresses and bed linen, but also

cracks/crevices and behind wallpaper

• Bed bugs can travel over 100 feet in one night

• Usually found within 8 feet of a sleeping area

• Bites may appear on skin, but some people show no

signs of being bitten by a bed bug

• Not a serious medical threat

• Avoid scratching bite areas

• Symptoms can be treated with antihistamines, and in serious

cases, steroids

http://www.cdc.gov/parasites/bedbugs/faqs.html#symptoms

-Patient moved four

times in as many

days

-Inconvenience of

multiple blocked

rooms in hospital

-Departure from

best practice No documentation of skin

assessment by ED MD who

assessed patient, of first

room pt. visited, or any

interdepartmental

conversations

Not enough communication

between disciplines: IC,

staff, MD, bedflow,

housekeeping

Multiple transfers of

patient

Multiple beds blocked

throughout hospital

Patient Satisfaction:

What message are we sending?

-Lack of concern

-Poor continuity

-Questioning our competence

No specific policy-

need to use internal

and external resources

Identified Root Causes

Documentation

Skin assessment

MDs and RNs

IC

Bedflow

Policy

No specific policy

…there won’t always be a policy.

Use the chain of command and your

internal/external resources

Utilization of Resources

IC

Bedflow

Housekeeping

Nursing

Transportation

Physicians

Communication

Handoff

Verbal

Written

Interdisciplinary

PATIENT

Just Culture Means

Accountability for Our Behaviors

Human Error

Inadvertent Action:Slip,Lapse,

Mistake

Manage through changes in:

Processes

Procedures

Training

design

At-Risk behavior

A Choice: Risk not recognized or

believed justified

Manage through:

Removing incentives for at risk behaviors

Creating incentives for healthy behaviors

Increasing situational awareness

Reckless

Behavior

Conscious disregard of unreasonable risk

Manage through:

Remedial action

Corrective action

CONSOLE COACH CORRECTIVE

Policy Change:

IC 11 – Infection Prevention for Clinical Departments