Just Culture Information
- Focus on evaluating the behavioral choices made by an individual, not on the outcome of the event;
- Require leadership commitment and modeling;
- Distinguish among normal human error, unintentional risk-taking behavior, intentional risk-taking behavior, and reckless behavior;
- Foster a learning environment that encourages reporting (including self-reports) of all near misses, mistakes, errors, adverse events, and system weaknesses;
- Lends itself to continuous improvement of work processes and systems to ensure the highest level of client and staff safety;
- Encourage the use of non-disciplinary actions whenever appropriate (including coaching, counseling, training, and education);
- Hold individuals accountable for their own performance in accordance with their job responsibilities; and,
- Does not expect individuals to assume accountability for system flaws over which they had no control.
Terms, Definitions and Examples:
Human Error (Not reportable to Board of Nursing)
- Nurse inadvertently, unintentionally did something other than intended or other than what should have been done;
- A slip;
- A lapse; or
- An honest mistake.
- Isolated event, not a pattern of behavior.
(Repetitive human error or pattern of behavior requires further evaluation)
- Single medication event/error (wrong dose, wrong route, wrong patient, or wrong time)
- Failure to implement a treatment order due to oversight
Responses to Behavior:
- Consoling or Coaching
(Board of Nursing Practice Consultant to be contacted for consultation)
- Behavioral choice that increases risk where risk may not be recognized or is mistakenly believed to be justified;
- Nurse does not appreciate risk;
- Unintentional risk taking; and
- Nurse’s performance or conduct does not pose a continuing practice risk to clients or others.
(Repetitive at-risk behavior or pattern of behavior requires further evaluation)
- Exceeding scope of practice
- Minor deviations from established procedure
- Nurse knowingly deviates from a standard due to a lack of understanding of risk to client, organization, self, or others
Responses to Behavior:
Coaching or Counseling
- If behavior not a pattern of practice) to raise awareness of accepted procedures and potential risks for failure to comply
- Remedial actions taken may include education, training, and assignment of activities appropriate to knowledge and skill
- Nurse may be informed failure to change is not an option
- If nurse does not accept coaching, may result in disciplinary action
- Non-disciplinary Remediation
- Disciplinary Action if Indicated
(Mandatory report to Board or Nursing required)
- Nurse consciously disregards a substantial and unjustifiable risk;
- Nurse's action or inaction is intentional and purposeful; or
- Nurse puts own self/personal interest above that of client, organization or others
- Nurse abandons patients by leaving workplace before reporting to another appropriately licensed nurse. Nurse leaves workplace before completing all assigned patient/client care (including documentation) for a non-urgent reason.
- Nurse does not intervene to protect a patient because nurse is not assigned to patient
- Nurse makes serious medication error, when realized tells no one, and when questioned denies any knowledge of reason for change in client condition
- Nurse falsifies documentation to conceal an error
Response to Behavior:
- Report to Board for Investigation
- Disciplinary Action by Board
Consoling – affording comfort or solace; restoring confidence and relieving anxiety.
Coaching – supportive discussion with an employee on the need to engage in safe behavioral choices.
Counseling – a first step in disciplinary action; putting an employee on notice that performance is unacceptable.