Читать книгу Quality and Safety in Nursing - Группа авторов - Страница 26

In a just culture, the focus is to determine what went wrong rather than identifying exactly who committed the error to establish blame and punishment (Armstrong, 2019). Just culture establishes an environment in which errors and near misses are acknowledged, reported, and analyzed for ways to improve the system. Organizations with a culture of safety have implemented processes through risk management to collect error reports for root cause analysis, often classifying with a tiered system of potential for harm. Carefully detailing all steps and decisions leading to an error or near miss can formulate a system redesign of processes that lessens the chance of future occurrence. The focus is on improving the system to prevent future errors rather than merely blaming individuals. Exploring what happened acknowledges the influence of complex systems and human factors that influence safety.