Q My nursing staff members are concerned after hearing the verdict in the Vanderbilt case. Are there implications for leaders?
This case has been a watershed moment for nurses and nursing practice. A watershed moment marks a unique or important historical change of course. In this case, the change of course needed is to improve and be more attentive to our practice and the practice environment.
Healthcare quality and patient safety require a culture grounded in effective leadership, science, resources, teamwork and collaboration, communications, and more. Previously, state, federal, and voluntary accreditation mandates drove quality and safety initiatives. Schroeder and colleagues believe a culture of quality and safety isn't created with one specific action, at one point in time, or with one enthusiastic leader, but includes a spectrum of components that must be identified, measured, developed, and enhanced.1 I'd add sustained and embraced by clinical staff.
To Err is Human: Building a Safer Health System and Crossing the Quality Chasm: A New Health System for the 21st Century strongly influenced quality efforts in healthcare and prompted leaders to ponder how to approach errors and quality findings. In addition, hospitals focused on nursing excellence began journeys to Magnet® recognition, including a greater focus on nursing sensitive indicators. These efforts were intended to provide a more deliberate assessment of quality, what impacted quality, and systems that supported quality patient care. They included but weren't limited to safety, effectiveness, efficient care, and patient outcomes.
According to Allhoff, medical errors are the third leading cause of death in the US but little work has been done to address associated questions, such as “What is a medical error?” He adds that the principal reason we care about errors is that they tend to lead to adverse events.2 Health systems aspire to eliminate errors and improve care outcomes, yet medical errors still happen. To this end, many organizations have embraced the philosophy of a “just culture.”3
A just culture is grounded in the belief that complex organizational and human systems can make it too hard to avoid errors. Assess systems, processes, and practices; identify teachable moments; and make improvements instead of taking a punitive approach with staff. This case dishonors David Marx's Just Culture model, a system of shared accountability in which organizations are accountable for the systems they've designed and for responding to their employees' behaviors in a fair and just manner.4
It's imperative that you're mindful of practices in your department that don't align with the American Nurses Association (ANA) Standards of Nursing, the ANA Code of Ethics, specialty standards, and policies. You have an obligation to identify and correct “workarounds,” consistently hold staff accountable for providing quality care, keep patients safe, and escalate concerns. Moreover, you need to remind staff that a task mindset isn't enough. It takes critical thinking around every aspect of care delivery, medication administration, procedures, and especially when to escalate an issue. Speak to how your practices, bundles, algorithms, and guidelines reflect best practice and the standards.
Leaders should be knowledgeable of issues that support care delivery and those that are barriers. What systems, processes, and standard work support practice? Are the proper equipment and supplies available and in working order? Is the organizational culture responsive to escalation or is there a blame orientation? Is the unit a psychologically safe place for staff to ask questions or is there bullying or an elitist mindset?
Provide a transparent, nonpunitive environment, with a focus on the organization. Avoid errors, think critically, and support clinical staff to connect clinical dots and understand the rationale for the task. There are implications and opportunities for leaders to have a significant role in improving patient care quality and safety.
1. Schroeder P, Parisi LL, Foster R. Healthcare quality improvement: then and now. Nurs Manage
2. Allhoff F. Medical error and moral luck. Kennedy Inst Ethics J
3. Reason J. Managing the Risks of Organisational Accidents
. London: Ashgate Publishing; 1997.
4. Raso R. Two wrongs don't make a right. Nurs Manage