Case-Study: Nonpunitive Culture of Safety

Case-Study: Nonpunitive Culture of Safety
Case-Study: Nonpunitive Culture of Safety
Case-Study: Nonpunitive Culture of Safety
Week 4: Nursing Roles in Quality Improvement 3131 unread replies.7676 replies. How do nurses promote patient safety and improve quality at your workplace? How do you report errors and near misses? What changes would you suggest be made on your unit or facility to improve a nonpunitive culture of safety?A non-punitive culture ? sometimes referred to by the trademarked term “Just Culture” ? is a
work environment in which staff are encouraged to deliver their best work possible in every
situation. When errors occur, the organization focuses on accountability of the individuals
involved and the context in which the error occurred. These organizations become learning
organizations that are committed to creating work environments where processes are developed
to always minimize errors and focus on safety. They are proactive in identifying and changing
system flaws at all levels of the organization.
In a non-punitive culture the individual is held accountable for his or her actions. The
organization acknowledges that human error is not only possible, it is likely under certain
circumstances. Staff are held to professional accountability in admitting errors, including their
own errors, to improve systems and prevent further errors. A non-punitive work environment is
one in which it is recognized that many individual errors are predictable and unavoidable when
human beings, including highly skilled human beings, interact with and use systems and
equipment. It acknowledges that individuals should not be held accountable for errors over
which they have no control.
A fair and just culture means giving constructive feedback and critical analysis in skillful ways,
doing assessments that are based on facts, and having respect for the complexity of the situation.
It also means providing fair-minded treatment, having productive conversations, and creating
effective structures that help people reveal their errors and help the organization learn from them.
Root cause analysis is often one of the first steps of analysis when an error occurs.
A non-punitive culture is the opposite of a blame culture. Individuals in a blame culture work
environment are held accountable for all errors regarding residents under their care, no matter
what the source of the errors. Even if lip-service is paid to the idea that “mistakes are bound to
happen once in a while,” the official reaction and process when an error does occur makes it
clear that mistakes never are supposed to happen. When a staff person makes an error, the
response in a blame culture work environment is to “re-educate” that employee and discipline
him/her. This method results in a work environment in which staff members are afraid to admit
to making errors. This culture results in staff demoralization, high human resources costs for
disciplinary efforts and to combat employee turnover, and the stifling of creativity and quality
improvement.
Applying these principles creates an opportunity to have the greatest impact on the safety of the
persons served and achieve the highest level of excellence. Staff can speak up about problems,
errors, and conflicts in an environment where the shared goal is the best environment for coworkers and respect, creativity, and teamwork are celebrated. The input of residents and their
families is valued and their satisfaction, safety, and outcomes based on personal preferences are
supported by all employees of the organization.