By now, I think all of us have heard enough about nursing practice, nursing standards, nursing credibility, nursing credentials, professionalism, evidenced based practice, blah-blah, etc, etc., ad nauseum.
There are plenty of writers and journals for all of that stuff, and I encourage them to keep at it, but I must say, it's often quite tedious and boring. I would rather make funny, with a rhyme, and tell the world what's really going on at the bedside.
Recently I noticed a "new" paper form in my workplace, named the "Just Culture Event Investigation".......(something like that). Apparently it is used when some type of Audit has been done, and an error was identified. What bothers me, is that since it is a new idea, why was I not made aware of this tool?
Frankly, I think the naming of the process is stupid. "Just Culture Event"?
1.) At first, I thought it was some kind of notice for a concert, or something like that; a Cultural Event. Perhaps a time to celebrate that dubious thing called, "Adversity". Well, adversity might be truthful, because if my Boss person, lays this form on me, I feel like I am in a situation of adversity, as in, bad luck, trouble, suffering, and misery.
2.) Second bothersome thing to me:
I don't know who the Auditor was. So, as I showed proof that my audited error, was incorrectly identified, why don't I have the opportunity to educate that person (the Auditor) and show them the error of their auditing method. In other words, that Auditor person should be served with their own "Just Culture Event Investigation" form.
What my Boss person said, when I pointed out the true error of the Audit: "Oh, then I'll just tear this one up". But I think that it is very likely, that there is an accounting somewhere, that shows I made an "error of omission" in my charting. That won't be corrected, because the Auditor won't be aware of their own error.
Because of all of this, I decided it was prudent and necessary that I perform some research on "The Just Culture". I am not surprised that big business has jumped on this and turned it into a money making scheme, with similarities to, "The Seven Pillars", "Project Redesign" and other nonsense.
It dates back to around the year 2001.
Patient Safety and the "Just Culture": A Primer for Health Care Executives.
Marx D. New York, NY: Columbia University; 2001.
Written prior to the acceptance of open disclosure or general policy support of it, the primer thoughtfully outlines the complex nature of deciding how best to hold individuals accountable for mistakes. Four key behavior concepts serve as the structure for the paper: human error, negligence, reckless conduct, and knowing violations. How they are applied to various situations in health care and how the individuals involved should be disciplined provide thoughtful reading.
And finally it slithers down to my workplace, thirteen years later.