Medication Errors: The Benefits of a Just Culture of Safety

Author: Karen Blum

Anesthesiology News

A “just” culture that allows for open communication of errors in a nonpunitive environment can and should be applied to critical evaluation of medication errors in hospitals and health systems, a patient safety expert said during the 2019 American Society of Health-System Pharmacists summer meeting.

“We know things go wrong all the time, every day in all of our hospitals,” said Karen Fiumara, PharmD, the executive director of patient safety at Brigham and Women’s Hospital, in Boston. “Is there a way for us to build a system where we can truly, fundamentally all work in an environment where every time something goes wrong that we can say we analyzed the event, we looked at the systems and contributors that led to that event, and remediated those, and in parallel we took care of the patient and the family?”

In that process, Dr. Fiumara added, “can [we be] completely, 100% supporting [of] our employees?”

A just culture of safety is an environment in which everyone is curious about why errors occur and where all employees feel a personal commitment to making care safer, Dr. Fiumara said. It also is one in which employees should be encouraged to be open about errors and the system vulnerabilities they see, as well as feel comfortable speaking up without fear of punishment.

The challenge is that “we can only fix what we know [about],” Dr. Fiumara said. Like an iceberg, “we only see the errors that break the surface and result in harm, but we have to remember that there is a ton of risk that is lurking just below the surface.”

Front-line staff often and almost always have the best insight into what works and what doesn’t, and can help identify problems to solve, she noted.

Dr. Fiumara said often clinicians in varying positions will tell her about errors knowing it’s confidential, but they feel afraid to share the information more publicly. Her colleagues aren’t alone. In a 2016 patient safety culture survey by the Agency for Healthcare Research and Quality, about six of 10 respondents said they feared they would be punished if they made a mistake. Although it may be “really unpopular to talk about some of the major and fundamental problems in our hospitals,” she said, that presents a key vulnerability and safety risk.

A just culture provides a framework to evaluate systems and behaviors to identify and fix vulnerabilities, Dr. Fiumara noted. Sometimes the risk lies in system practices; sometimes it results from individual behaviors, but most often it results from a combination of the two.

A just culture should be viewed not about finding fault but in managing risk, she added. While we tend to judge the quality of an individual health care worker’s choice based on the outcome of the patient affected by an error, and base punishment on that outcome, we have to remain curious about why a mistake happened. When investigating, it’s important to keep calm to explore all contributing factors to an error, she said.

Behaviors contributing to medication errors tend to fall into three main categories: human error, an inadvertent act that could happen to anyone; at-risk behavior, a risk believed to be justified because other colleagues do the same thing; and reckless behavior, a conscious disregard of substantial, unjustified risk.

In the first two cases, the organization may choose to support or coach employees to better practices, whereas reckless behavior calls for more serious corrective action or firing, she said. These cases are rare, however. Dr. Fiumara said in 10 years working in patient safety, she has seen just two instances of this.

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