Читать книгу Kelly Vana's Nursing Leadership and Management - Группа авторов - Страница 263

Ultimately, the just culture model creates a learning culture that is open and fair; manages behavioral choices; and designs safe health care systems. An HRO cannot exist in the absence of learning. The learning organization is an organization where people continuously learn and enhance their capabilities to create (Senge, 1990). Nurse leaders in HROs view each failure as an opportunity to learn from mistakes. They readily admit weaknesses and commit to learning from its mistakes. They take a systems approach to safety and improving the culture of safety. Nurse leaders in these organizations create a supportive learning environment by putting processes in place to facilitate learning and encourage creativity among employees. Such a learning environment requires transparency related to safety, so that everyone is aware of opportunities for improvement.

Reporting errors and near miss safety events can assist in understanding a problem rather than hiding that a problem exists. As a result, nurse leaders must put tactics in place to increase error reporting. Speaking up for safety may appear to be easy. Health care providers come into health care to do the right thing, help patients, and cause no harm. However, errors happen. In an HRO, all health care providers are responsible for reporting safety events, including near misses, adverse events, and sentinel events. This type of reporting has its limitations, as it depends on both the recognition of the safety event and the completion of a safety event report. When using voluntary reporting and error tracking, only around 10 to 20 % of all errors are reported in health care organizations (Classen, et al., 2008). A study of Medicare beneficiaries found that only 14 % of patient harm events were captured in hospital incident reporting systems (Health and Human Services, 2012). Nurse leaders must encourage and reward staff who report safety events and decrease the fear inherent in error reporting.

This starts with a robust error‐reporting system which can be easily accessed and completed by direct‐care nurses and other clinicians. Next, nurse leaders need to thank staff for reporting errors, mistakes, events, and near misses. The Good Catch award, implemented in many hospitals across the country, is one way to recognize staff who report near misses or close calls. Edward Hospital in Naperville Illinois implemented the Good Catch award in 2008. Each month, Risk Managers compile a list of safety events that have been identified by staff and have not reached the patient to cause harm. Members of the senior leadership team vote on the most significant event. The person or team is recognized at a Management Team meeting and receives a certificate, a lapel pin, and a Good Catch trophy. The program recognizes those who speak up and fosters a culture of transparency and safety.

Speaking up for safety requires more than reporting actual or potential errors. It also involves clinicians stopping a care process whenever a member of the care team has a safety concern. This may be uncomfortable for clinicians who have historically viewed health care as hierarchical. As a result, nurse leaders must clearly communicate that everyone has the authority to stop for a safety concern at any time. Nurses are expected to voice their concern and “stop the line” if they sense or discover a safety issue. The acronym CUS may be used. The letters represent “I am Concerned;” “I am Uncomfortable;” and “This is a Safety Issue.” Consider this powerful and effective way of speaking up: “I am concerned with Mr. Lopez's sudden hemiparesis and am concerned with your choice of not implementing the stroke protocol. I believe this is a safety issue.”