UNDERSTANDING NURSING MANAGEMENT AND ORGANIZATIONS
A just culture, in contrast, allows for reporting of errors without fear of undue retribution (Gorzeman, 2008). Khatri, Brown, & Hicks (2009) suggest that transitioning to a just culture does more than improve reporting mechanisms or initiate training programs. A just culture provides an environment in which employees can question policies and practices, express concerns, and admit mistakes without fear of retribution. A just culture requires organizational commitment, mana- gerial involvement, employee empowerment, an accountability system, and a reporting system (Gorzeman, 2008).
Accountability for errors, however, must be maintained (Gorzeman, 2008). Errors can be categorized as:
● Human errors, such as unintentional behaviors that may cause an adverse consequence ● At-risk behaviors, such as unsafe habits, negligence, carelessness ● Reckless behaviors, such as conscious disregard for standards
A just culture is prepared to handle incidents involving human error. At-risk or reckless behaviors, however, are not tolerated.
Managing and improving quality requires ongoing attention to system-wide processes and individual actions. The nurse manager is in a key position to identify problems and encourage a culture of safety and quality.
RISK MANAGEMENT Yasmine Dubois is the nurse manager for the cardiac catheterization lab and special procedures unit in a sub- urban hospital. The hospital has an excellent reputation for its cardiac care program, including the use of cut- ting-edge technology. The cath lab utilizes a specialized computer application that records the case for the nurs- ing staff, requiring little handwritten documentation at the end of a procedure.
Last month, a 56-year-old woman was brought from the ER to the cath lab at approximately 1900 for place- ment of a stent in her left anterior descending coronary artery. During the procedure, the heart wall was perfo- rated. The patient coded and was taken in critical condi- tion to the OR, where she died during surgery.
Two days following the incident, the patient’s hus- band requested a review of his wife’s medical records. During his review, he pointed out to the medical records clerk that the documentation from the cath lab stated that his wife “. . . tolerated the procedure well and was taken in satisfactory condition to the recovery area.” The documentation was signed, dated, and timed by Elizabeth Clark, RN. The medical records director
notified the hospital’s risk manager of the error. The risk manager investigated the incident and determined that Elizabeth Clark’s charting was in error.
Following her meeting with the risk manager, Yas- mine met with Elizabeth to discuss the incident. She showed Elizabeth a copy of the cath lab report. Eliza- beth asked Yasmine if she could have the chart from medical records so she could correct her mistake. Yas- mine informed Elizabeth that she couldn’t correct her charting at this point in time. But, she could, however, write an addendum to the chart, with today’s date and time, to clarify the documentation. Yasmine also told Elizabeth that the addendum would be reviewed by the risk manager and the hospital’s attorney prior to inclusion in the chart.
To ensure compliance with the hospital’s documen- tation standards and to determine if Elizabeth or any other cath lab nurse had committed any similar charting errors, Yasmine requested charts for all patients in the past 12 months who had been sent to surgery from the cath lab due to complications during a procedure. She conducted a retrospective audit and determined that this had been an isolated incident.