Just Culture – Entry 2

Dear Diary:

I brought Anna (RN) and Sherry (NA) together to talk about what happened and to share their feelings about Hattie’s fall. They were able to clear the air by really listening to each other and sharing what happened. I then brought the rest of the team together to discuss the events that took place. I reinforced the concept of “just culture” and how important it is for us to work together to create a non-blaming, non-punitive culture here at River View.

I feel like the team better understands that when an event happens, rather than just blaming someone, it’s important to talk about and determine the root cause of the event. In this case, Sherry didn’t have time to put a transfer belt on Hattie since our resident was in the middle of transferring herself when Sherry entered the room. We could have had a number of other reasons such as a transfer belt was unavailable, it wasn’t communicated that Hattie needs to be transferred with a transfer belt, or Hattie may have refused to use a transfer belt. There is a reason for everything. Working as a team to understand the reason, we can hopefully prevent it from happening again.

We talked about the three behaviors of a just culture: human error, at-risk behavior, and reckless behavior. I certainly don’t think Sherry was using reckless behavior since she did not intentionally choose to not use a transfer belt. The team seemed to understand. Anna needs to do a better job of coaching her nursing aides to work together to prevent future occurrences rather than jumping right away to the “blame game”.

We’ve still got some work to do, but I think we’re making some strides in creating a just culture around here.

Signed, Donna

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