Just Culture and Patient Safety – Health System Example

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"Just Culture and Patient Safety" is a perfect example of a paper on the health system. In an address to leaders of a hospital in the Midwest, Panten and Torrance (2014) generated vital ideas related to safety practices. In an attempt to safety in a health care setup, professionals should double-check the sites for operations prior to incision. Determining a health care professional deserves disciplinary sanction that entails defining or describing the implication of disciplinary action. In most cases, it is an assumption that disciplinary actions are detrimental arrangements dispensed by authorities to eliminate chances of future occurrence of undesirable conduct.

“ Just Culture” advocates punishing individuals for mistakes made in the medical industry. Panten and Torrance (2014), outline three key principles that are fundamental in developing a just culture. In addition, the just culture entails the following core virtues, trust, and accountability, learning, and continuous improvements. A Balanced Approach to Error To illustrate just the culture concept, the article gives the case involving Chesley Sullenberger, a pilot who safely landed an incapacitated jet in the Hudson River. Traditionally in the health care sector, a punitive culture has been in existence.

The culture discouraged reporting safety occurrences and in effect, patients suffered. To eliminate it, the Just culture emerged recognizing that mistakes are inevitable in humans who should share accountability. Establishing a Just Culture The principle of building broad consensus is fundamental in establishing a just culture. The principle stipulates that all members in a hospital or organization should understand the just culture comprehensively before it becomes a practice. Communicating accountability to staff is the second principle. Just culture critically distinguishes between human error, at-risk behavior, and reckless behavior, all of which a hospital setup outlaw.

Human error is a social label with a low quantification threshold. Human errors are inevitable and, as such, individuals commit them in their daily course of duties unintentionally with minimal consequences. Health care professionals commit these types of errors though not at a greater frequency during off-work hours. Such terms like a mistake, slip, and lapse is applicable to describe human errors. The third principle concerns the acceptance of the administration’ s accountability. Just culture assumes that causes of the error include poorly managed systems of care and human behavior.

Nursing leaders should recognize process risks and adopt steps to design efficient scheduling systems. There are three disciplinary decision-making policies and strategies. They include outcome-based disciplinary decision-making, rule-based method, and risk-based disciplinary decision-making. The strategies aim at quantifying and evaluating the nature of every individual’ s action. Choice of Article Panten and Torrance (2014), comprehensively outlines the practices that a nursing professional should value to gain success. It addresses the safety practices for the nursing profession hence should be a guide that all nurses use during the professional practice. Lessons Based on the article by Panten and Torrance (2014), it is evident that within a just culture organization, mistakes, and errors must not ultimately result in automatic punishment.

It should incorporate steps and processes of uncovering the cause of the error. Knowledge is fundamental in the nursing profession and aids in enhancing better relations among nursing professionals.


Panten, N & Torrance, A. (2014, January 13). Just Culture: The Missing Ingredient in Patient Safety. . ExecutiveInsight. Retrieved November 17, 2014, from http://healthcare-executive-insight.advanceweb.com/Features/Articles/Just-Culture-The-Missing-Ingredient-in-Patient-Safety.aspx
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