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Author Question: A large health care organization has committed to promoting a just culture when adverse events and ... (Read 23 times)

corkyiscool3328

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A large health care organization has committed to promoting a just culture when adverse events and near misses take place. Which question will guide the organization's response when a nurse commits an error?
 
  A) How did the nurse's actions contribute to this error?
  B) How have other organizations responded to nurses in events like this?
  C) Have the client and the family been informed about this?
  D) What is the organization's legal liability in this matter?

Question 2

Root cause analysis is being performed after a client who was supposed to be on falls precautions fell while trying to walk to the toilet. Which finding of the investigation would be considered to be a latent error?
 
  A) The documentation forms on the unit have no specified location where falls precautions should be noted.
  B) The client's primary nurse went on a scheduled break without reporting off to a colleague.
  C) The nurse manager mistakenly admitted the client into a room far out of site of the nurses' station.
  D) A nursing assistant on the unit admitted to ignoring the client's call light before the client fell.



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TheNamesImani

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Answer to Question 1

Ans: A
Feedback:
Key to the establishment of a just culture is a recognition that not all errors are the same, and that nurses' contributions to errors vary greatly. Legal liability, the response of other organizations, and communication with the client are valid considerations, but none directly promote the establishment of a just culture.

Answer to Question 2

Ans: A
Feedback:
An omission on the documentation forms that are in use on a unit is an example of a latent error that can culminate in an adverse event. Each of the other listed actions are active errors that specific individuals made, all of which contributed directly to the client's fall.





 

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