Just Culture – Entry 1

Dear Diary:

Well, today was a tough day. I think one of my challenges at River View Rehabilitation and Care Center is going to be trying to get everyone to work together as a team. Everyone is so quick to point fingers when something goes wrong. Take today, for example.

Sweet Hattie who’s 92, came to us from her home after being treated for pneumonia and dehydration in the hospital and she has been really weak. I imagine her psychotropic meds contribute to this weakness. Hattie was in bed and needed to go to the bathroom, so she called for the nurse. When Sherry, one of our nursing aides, went into her room, Hattie was already trying to get out of the bed herself so Sherry went to help her. For some reason the NA didn’t use a transfer belt. Hattie’s legs gave out when the NA tried to help and she ended up falling on the floor.

At that point, Sherry pulled the call button for assistance and a nurse came in. They assessed Hattie and determined that she had possibly fractured her hip. They called our doctor who said to call 911 and now she’s back in the hospital.

Evidently, the nurse scolded Sherry, which of course made her feel bad and start crying. The incident report said the reason for the fall was because a nursing aide didn’t use a transfer belt. Technically, that may have been the case, but I want the nursing staff to think more deeply than that.

How do I convince everyone that rather than blaming someone else, what could have been done to prevent this?

How can we work more as a team rather than blaming one another?

Signed, Donna


  • I love this idea. When will you be publishing more of these.

    • We plan to publish more entries before the end of June. Once the nursing homes participating in the ATTAX campaign select the topic areas they plan to work on, Stratis Health will be developing more frequent diary entries to tied to those areas to support nursing home learning and quality improvement.

  • Well, we had another fall with injury. Hattie, a fairly new resident, fell and broke her hip. Her daughter, Carol stopped by to talk with me. Naturally, she was upset. I told her that we’d investigate the details and get back to her. I’ve got Donna doing some follow-up. We’ll meet later today to talk about what she found and together call Carol. Building trust with families is so important. I also have to talk with Donna about our fall rates and what we can do to decrease those rates. Probably should be on the agenda of our next manager meeting also. It’ll take everyone to bring those rates down. I also heard that Sherry was upset. She was the nursing assistant involved with the fall. I think I’ll go talk with her and see what she has to say about the incident.

  • I walked into Hattie’s room as she was trying to get out of bed. I rushed to her and grabbed her arm but she fell before I got a good hold of her. It looks like she broke her hip. I feel so bad. Hattie was confused, looking for her husband and I know she’s been a widow for a long time. I pulled the call light and hollered for help. Anna came quickly, thank goodness, and told me to stay with Hattie while she called the doctor and 911. After Hattie was transferred, Anna yelled at me for not using a transfer belt. I know she was upset, but she didn’t listen to me. I told the other nursing assistants. They suggested I go talk with Anna when she’s not so busy. Maybe I will.

  • Hattie, a new resident fell and broke her hip. I heard a yell from her room. Sherry was standing over her. She said Hattie was trying to transfer and fell. It was obvious her hip was broken. I called the doctor and 911. After Hattie was transferred, I was so angry. It looks like Sherry didn’t even grab a transfer belt before moving her. I told Sherry it was her fault Hattie fell. I know she was upset, but so was I. Why can’t the nursing assistants think ahead to what might happen?

Share your nursing home perspective on this quality improvement issue.