Posted: March 21st, 2015

From the Marx primer re: “Just Culture,” define the 4 behavioral concepts integral to understanding the relationship between discipline and patient safety; then apply each of these concepts to the example that Dr. Victoria Rich presents in her video regarding a nurse giving a medication via the wrong route that results in a sentinel event

• From the Marx primer re: “Just Culture,” define the 4 behavioral concepts integral to understanding the relationship between discipline and patient safety; then apply each of these concepts to the example that Dr. Victoria Rich presents in her video regarding a nurse giving a medication via the wrong route that results in a sentinel event

1- Definition of Human Error
• Human Error is a social label. It may be characterized as follows:
• When there is general agreement that the individual should have done other than what they did, and in the course of that conduct inadvertently causes or could cause an undesirable outcome, the individual is labeled as having committed an error.
• Human error is a term that we use to describe our everyday behavior – missing a turnoff on the freeway, or picking up strawberry ice cream instead of chocolate. The threshold for labeling behavior “human error” is very low – we make errors every day with generally minimal consequences. In the health care profession, we make similar types of errors – perhaps not at the frequency of those in our off-work hours, but often with much more potential for dire consequences. We use terms like mistake, slip, and lapse to basically tell the same story – that someone did other than what they should have done, and inadvertently caused an undesirable outcome. When a physician prescribes the wrong dosage, we will likely label her actions a human error. We understand that the physician did not intend her error or its undesirable outcome even though the consequences are potentially life threatening.
Apply the victoria example,
In Victoria’s example a patient had terminal cancer with an NG, Central line and oral Dilantin. The patient consistently pulls the NG out and the Nurse, who is new, called the doctor. The doctor ordered to put back the NG and gave her Dilantin because she had seizure. The meds is always in the patient room and no one took the oral Dilantin out of the room so the nurse injected the oral syringe in the central line. And then the next day the patient died. So in this case the nurse did intend her error, but she did something that should not have been done. Her action is labled as an a human error

2. definition of Negligent Conduct
Negligence, at least in our social dialogue, is conduct subjectively more culpable than human error. Negligence, as a legal term, arises from both the civil (tort) and criminal liability systems. Negligence is the term generally used when an individual has been harmed by the healthcare system. A basic tenant of common law is that he who is negligent must pay for the resulting damages. In most states, negligence is defined as failure to exercise the skill, care, and learning expected of a reasonably prudent health care provider.3 Criminal negligence, as defined by the Model Penal Code, involves an objective determination that a person should have been aware that they were taking a substantial and unjustifiable risk toward causing an undesirable outcome.4
Apply the victoria example,
In this case the negligence is defined as failure to exercise learning expected of the nurse. The management wanted to fire the nurse, because she made an error that resulted to an undesirable outcome, which in this case death.

3- Definition of Reckless Conduct
Reckless conduct, alternatively referred to as gross negligence, involves a higher degree of culpability than negligence. Reckless conduct in both the civil liability and criminal systems involves conscious disregard of risk.5 Reckless conduct differs from negligent conduct in intent; negligence is the failure to recognize a risk that should have been recognized, while recklessness is a conscious disregard of a visible, significant risk. Consider the term “reckless driving.” For most of us, it connotes a much higher degree of culpability than mere human error.
Apply the victoria example,
In Victoria’s example, the nurse consciously disregarded and injected Dilantin via the wrong rout in a central line.

4- definition Intentional Rule Violations
Most rules, procedures, and duties will require or prohibit a specific behavior. The intentional rule violation occurs when an individual chooses to knowingly violate a rule while he is performing a task. This concept is not necessarily related to risk taking, but merely shows that an individual knew of or intended to violate a rule, procedure, or duty in the course of performing a task.
Apply victoria example,
The nurse knew that she violate a duty in the course of administering an oral Dilantin in the central line. She confessed that she made an error to the Chief Nurse executive
Dr. Sexton (in the posted webinar) discusses the concept of Resiliency in healthcare (to an audience of NICU staff). How does he define it and how does this concept relate to a culture that facilitates patient safety ?

He defines resiliency as a healthcare provider’s ability to cope and function, and weather or not the recourses is available for the healthcare provider’s health and wellbeing. It is 30% of a person genes and the way he/she raised the other 70% is from access and the availability of resources that the person has. For example, the opportunity to sleep and spen a quality time with family etc.

how resiliency relate to a culture that facilitates patient safety

• Healthcare system drain healthcare providers to do more
• Cognitive consequences of sleep and sleep loss ( one night of sleep deprivation cause 40% reduction in ability to form new memory and negative memories are most resilient to fatigue,
• Half of the critical care nurses emotionally exhausted, 2 out of three have difficulty sleeping and 1 out of 4 are depressed
• The concept affects the healthcare provider by thinking in a negative loop. For example, a healthcare provider keeps saying to himself “I overdose a neonatal baby” over and over. Thehealthcare provider does not learn from the experience rather the healthcare provider is destroying himself from inside I.e the healthcare providers progress in to that negative spiral. This behavior affects a healthcare provider physically emotionally. Also, being in a negative loop can compromise identity of a person. So by being cynic, negative, shameful and doubtable affect the culture of work and in return affect patient safety. For example, in hospital with high patient/ nurse ratios, surgical patients experience higher risk-adjusted 30-day mortality and failure to rescue rates, and nurses are more likely to experience burnout and job dissatisfaction. Another example, results 20% of residents met the criteria for burnout. Active survelliance yielded 45 errors made by participants. Depressed residents made 6.2 times as many medication errors
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