Discussion: Group Management for Just Culture The concept of a fair and just culture refers to the way an organization handles safety issues. Humans are fallible; they make mistakes. In a just culture, ‘hazardous’ human behavior such as staff errors, near–misses and risky actions are identified and discussed openly in hopes of finding ways to improve processes and systems—not to identify and punish the individual. —Pepe & Caltado, 2011 This Discussion examines the opportunities of managers in working with groups to promote change that facilitates the delivery of safe, high–quality care. To Prepare Review the information on just culture presented in the Learning Resources. For this discussion, you will use the Regulatory Decision Pathway found in Russell, K. A. & Radtke, B. K. (2014). Examine an adverse event at the unit level in your organization or one with which you are familiar and apply the Regulatory Decision Pathway. Compare the findings of the Regulatory Decision Pathway  to what actually happened at the unit in your organization. Was the event deemed:  bad intent, reckless, at risk, or human error ? According to the pathway, do you now think it was the correct action? Think about how a nurse leader–manager may use just culture as a framework to create or maintain a focus on accountability and outcomes throughout a group. What actions could be taken if a systems–related error was made or if an error resulted from risky behavior? How might role conflict and/or ambiguity have contributed to the situation? Post a  description of an adverse event  in your organization and your analysis of the issue using the Regulatory Decision Pathway. Explain how role conflict or ambiguity might have influenced this situation. Apply the principles of just culture as you explain how you, as the group’s manager, would handle the situation. http://sidneydekker.com/wp-content/uploads/2013/01/JustCultureCritique.pdf http://www.outcome-eng.com/wp-content/uploads/2012/01/manage-risk.pdf **************Below is a paper to use as reference!!!!!!!!! PLEASE USE THIS AS A REFERENCE ONLY. Adverse Event             Adverse events are a part of the healthcare environment and how an event is dealt with can affect patient safety.  The regulatory pathway and just culture are a means of improving the quality of care and safety culture (Russell & Radtke, 2014).  Health care employees need to trust in their organization that an adverse event can be reported so that the organization and employee can learn from the event, and that it is not just a means to place blame.             An adverse event that took place in the cardiac catheterization lab was a procedure was done on the wrong patient.  A patient that was to have a pacemaker instead ended up having a diagnostic catheterization.  This event involved a patient identification issue by the nurse.  The hospital’s patient identification policy and time out policy were not adhered to by the nurs.

1. Discussion: Group Management for Just Culture
The concept of a fair and just culture refers to the way an
organization handles safety issues. Humans are fallible; they
make mistakes. In a just culture, ‘hazardous’ human behavior
such as staff errors, near–misses and risky actions are identified
and discussed openly in hopes of finding ways to improve
processes and systems—not to identify and punish the
individual.
—Pepe & Caltado, 2011
This Discussion examines the opportunities of managers in
working with groups to promote change that facilitates the
delivery of safe, high–quality care.
To Prepare
Review the information on just culture presented in the
Learning Resources.
For this discussion, you will use the Regulatory Decision
Pathway found in Russell, K. A. & Radtke, B. K. (2014).
Examine an adverse event at the unit level in your organization
or one with which you are familiar and apply the Regulatory
Decision Pathway.
Compare the findings of the Regulatory Decision Pathway to
what actually happened at the unit in your organization. Was the
event deemed:

2. bad intent, reckless, at risk, or human error
? According to the pathway, do you now think it was the correct
action?
Think about how a nurse leader–manager may use just culture as
a framework to create or maintain a focus on accountability and
outcomes throughout a group. What actions could be taken if a
systems–related error was made or if an error resulted from
risky behavior?
How might role conflict and/or ambiguity have contributed to
the situation?
Post
a
description of an adverse event
in your organization and your analysis of the issue using the
Regulatory Decision Pathway. Explain how role conflict or
ambiguity might have influenced this situation. Apply the
principles of just culture as you explain how you, as the group’s
manager, would handle the situation.
http://sidneydekker.com/wp-
content/uploads/2013/01/JustCultureCritique.pdf
http://www.outcome-eng.com/wp-
content/uploads/2012/01/manage-risk.pdf
**************Below is a paper to use as reference!!!!!!!!!

3. PLEASE USE THIS AS A REFERENCE ONLY.
Adverse Event
Adverse events are a part of the healthcare environment
and how an event is dealt with can affect patient safety. The
regulatory pathway and just culture are a means of improving
the quality of care and safety culture (Russell & Radtke, 2014).
Health care employees need to trust in their organization that
an adverse event can be reported so that the organization and
employee can learn from the event, and that it is not just a
means to place blame.
An adverse event that took place in the cardiac
catheterization lab was a procedure was done on the wrong
patient. A patient that was to have a pacemaker instead ended
up having a diagnostic catheterization. This event involved a
patient identification issue by the nurse. The hospital’s patient
identification policy and time out policy were not adhered to by
the nurse and then the catheterization team. The incident was
reported to the state, and there were several event meetings with
the nurse and physician. As a result of the investigation, all
staff in the catheterization lab were re-educated to the patient
identification and time out policy. All staff had to sign an
individual affidavit that they understood the policy. The nurse
was given a written warning. This event would not have
happened if the nurse and catheterization team had adhered to
policy.
Regulatory Decision Pathway
Using the regulatory decision pathway, the nurse did not intend
to harm the patient deliberately. The nurse asked the patient if

4. she was Ms. X and the patient said yes. The identification
policy is to check the patient’s identification band for name and
medical record number against a second identifier. This was
not done. There were no significant circumstances involving
the system that led to the error. The nurse did not conceal the
error or falsify the record. The nurse did not disregard or
consciously take a substantial risk. She thought she had the
correct patient. There were no similar or serious errors by this
nurse. A reasonably prudent nurse would not have done the
same in similar circumstances as the patient identification
policy would have been adhered to. According to the regulatory
decision pathway, this was at-risk behavior by the nurse
(Russell & Radtke, 2014).
The catheterization team which included the physician,
nurse, physician assistant, and technician contributed to this
adverse event. The team did not follow the time out process
policy where everything stops, and patient identification is
reconfirmed with other parameters. Again, following the
regulatory decision pathway, the catheterization team
demonstrated at-risk behavior. At-risk behavior involves unsafe
practice and carelessness which is shown by the nurse and
catheterization team not adhering to policy (Russell & Radtke,
2014).
Role Conflict
The cardiac catheterization lab is very fast-paced, and the
nurses can feel the stress of the workload. The procedure area
and recovery room was very busy and crowded that day. Role
conflict could have contributed to the situation as there is
constant pressure to keep moving. Role conflict could have
contributed in the time-out process not taking place in the
procedure room. Nurses have to initiate the time out process
when the physician arrives, and some physicians are not very
cooperative in the process. Since the adverse event, patient

5. identification and the time out policy are strictly adhered to.
Just Culture
Quality improvement and work environment improvement are a
part of just culture (Lockhart, 2015). Just culture is safety
issues, improving processes, and not about punishing
individuals (Pepe & Cataldo, 2011). As the group’s manager
using the principles of culture, I would have done firm
counseling stressing the significance of the incident, but as this
was the nurse’s first risky behavior, I would not have done a
formal written warning with the threat of being fired if it
happens again. Doing a staff meeting and re-educating the
policies was appropriate. Patient identification and the time out
process are now part of the cardiac catheterization lab’s
monthly quality assurance surveys. All new employees are well
educated in the two policies and must sign an attestation that
they understand by the end of orientation. This adverse event
led to improved processes in the cardiac catheterization lab
which is the goal of just culture (Pepe & Cataldo, 2011).
References
Lockhart, L. (2015). Does your organization have a just
culture? Retrieved from
http://www.NursingMadeIncrediblyEasy.com doi-
10.1097/01.NME.0000457286.16594.92
Pepe, J., & Cataldo, P. J. (2011). Manage risk, build a just
culture.
Health Progress
. Retrieved from http://www.outcome-eng.com/wp-
content/uploads/2012/01/manage-risk.pdf

6. Russell, K. A. & Radtke, B. K. (2014). An evidence-based tool
for regulatory decision-making: regulatory decision pathway.
Journal of Nursing Regulation
, 5(2), 5-9.
https://class.waldenu.edu/bbcswebdav/institution/USW1/201810
_27/MS_NURS/NURS_6201/readings/USW1_NURS_6201_Russ
ell.pdf