Just Culture

No. This is not a post about going to the theater. Or the symphony. Or a museum.

According to http://www.justculture.healthcare it is the balancing of accountability and safety.

Not only the safety of the patients but the accountability and safety for the nurse.

It is learning from mistakes. Not stifling the reporting of said mistakes.

It is doing a deep dive into why the mistake happened, not blaming the nurse who caused the mistake.

RaDonda Vaught realized and reported her mistake immediately. As she should have. It was a lethal mistake with so many things wrong with it. A perfect example of swiss cheese model of errors that can harm a patient. What happened after that is on the hospital. But we are not hearing anything from the hospital.

Instead, they did not report it as they are mandated to. This was a sentinel event. A sentinel event is an event in which the patient died or was seriously injured. This poor patient and the events leading to her death was not reported in any stretch of a reasonable amount of time.

Was this a tragedy? Yes.

Am I sure that RaDonda Vaught is remorseful? Yes.

Every healthcare system and hospital that I have worked for stresses that there will be no blame. A mistake should be reported immediately so that what happened can be examined.

But I fear that the self-reporting will go WAY down after this. Should a prudent nurse report problems like what occurred? Yes. But no one wants to harm a patient. No one wants to go to jail.

However, convicting the nurse of negligent homicide makes all of patients, mine, yours, the hospitals, a little less safe.

Just for a wee bit of irony, RaDonda Vaught’s sentencing date is May 13, 2022.

The day after the end of Nurse’s Week.

The day after Florence Nightingale’s birthday.

Makes you hum in introspection. Makes you think.

It makes me think.

Edit 4/6/2022 0903 EST: Today news of a nurse being indicted in NC to an inmate death after officers dogpiled on him, held him down with his hands behind his back, ignored him while he cried out for his mother and said that he couldn’t breathe. She tried to help him, no charges for the officers.

Every nurse should be scared.

The scapegoating of nursing has begun.

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