Just Culture Requires Just Response

Dear Colleagues,

In 2017 a nurse employed by the Vanderbilt University Medical Center mistakenly administered the wrong medication that, reportedly, led to a patient’s death. The events that followed this medical error are both concerning and valuable for organizations to recognize and discuss. Last week a federal trial by jury convicted this former Vanderbilt University Medical Center nurse of criminally negligent homicide and impaired adult abuse. Make no mistake about it; classifying an unintentional medical error as a criminal act, especially one that was self-reported, is diametrically opposed to the values we hold as an organization (ICARE) and our principles of Just Culture and High Reliability.

I want to take this opportunity to make it clear to all of you that we at the North Florida / South Georgia Veterans Health System are committed to becoming a High Reliability Organization (HRO). A pillar of this journey towards Zero Harm is implementing a Just Culture through utilizing the Just Culture algorithm and responding to medical error justly. A cultural of safety is one in which staff feel safe to report errors, trust that leaders will respond justly to those errors, and that through its established processes. We as an organization can use the lessons learned from the error to improve our systems and prevent future negative events.

As we have learned in HRO Baseline, Just Culture, and Clinical Team Training (CTT), errors are ubiquitous. There is no one that is immune from making some sort of error. They are unavoidable and will happen, especially in the complex world of healthcare. Punishing staff for making unintentional errors will only lead to silence and the loss of an opportunity to learn from these mistakes and ultimately?can cause harm to our Veterans. This unjust approach to responding to error; as seen in Vanderbilt UMC; reinforces how critically important it is for the Veteran Health Administration to lead the way with high reliability. As leaders we are accountable for a Just Response to error and accepting equal responsibility for failures, especially when they occur within the systems and processes that we designed. Our focus as leaders should be not on punishing errors, but on working with staff to implement systems and controls that mitigate risks, trap errors, and improve processes to staff and patients.

As your executive leader I acknowledge these points written above. I will always do my very best to respond justly to errors and failures that occur with our healthcare system. I will be a staunch defender of these values and principles we hold dear. This does not mean that we are not accountable for impaired, reckless, or malicious behaviors/actions. However, what it means is that we should always focus on the process first and not the person. We will always view error though the lens of Just Culture.

Although this verdict is not precedent setting, I realize it can be chilling and that is why I wanted to assure you all that I will never abandon you for doing your very best, aligning with our ICARE values in the work that you perform, and reporting errors that occur. We are all responsible for improving our system, the work we do, and the culture that we desire.

?DAVID ISAACKS, FACHE

Executive Health System Director

Follow the North Florida/South Georgia Veterans Health System