A Just Culture Approach to Managing Medication Errors

Hospital Pharmacy
Erin RogersRobert J Weber

Abstract

Medication errors continue to be a concern of health care providers and the public, in particular how to prevent harm from medication mistakes. Many health care workers are afraid to report errors for fear of retribution including the loss of professional licensure and even imprisonment. Most health care workers are silent, instead of admitting their mistake and discussing it openly with peers. This can result in further patient harm if the system causing the mistake is not identified and fixed; thus self-denial may have a negative impact on patient care outcomes. As a result, pharmacy leaders, in collaboration with others, must put systems in place that serve to prevent medication errors while promoting a "Just Culture" way of managing performance and outcomes. This culture must exist across disciplines and departments. Pharmacy leaders need to understand how to classify behaviors associated with errors, set realistic expectations, instill values for staff, and promote accountability within the workplace. This article reviews the concept of Just Culture and provides ways that pharmacy directors can use this concept to manage the degree of error in patient-centered pharmacy services.

References

Dec 9, 2003·International Journal for Quality in Health Care : Journal of the International Society for Quality in Health Care·William B RuncimanRobert J Adams
Mar 17, 2005·JAMA : the Journal of the American Medical Association·Joel S WeissmanNancy Ridley
Jul 16, 2010·JAMA : the Journal of the American Medical Association·Peter J Pronovost

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Citations

Jul 8, 2021·The Canadian Journal of Nursing Research = Revue Canadienne De Recherche En Sciences Infirmières·Chantelle Bailey, Lianne Jeffs

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