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Rice Memorial Hospital eyes 'just culture' model of patient safety accountability

WILLMAR -- A decade ago, a nurse or other hospital employee who made a mistake -- especially if it resulted in harm to a patient -- could expect to be disciplined and punished, regardless of how or why the error occurred.

Starting in the late 1990s, the focus began to shift away from blaming individuals to looking at the system.

Did hand-written orders make it too hard to read the name of the drug or the dose? Were nurses trying to function in an environment that was noisy, chaotic and full of interruptions? Were there loopholes in how information was communicated?

Individuals shouldn't be the scapegoat if it was really the system that was at fault, the new thinking went.

But something was still missing: accountability.

Rice Memorial Hospital is among a growing number of hospitals that have begun looking at -- or have already adopted -- a "just culture" model, an attempt to stake out the middle ground between blaming individuals and holding them accountable.

Rice Hospital leaders will attend a day-long training session on the concept in March. They'll then decide whether the just culture model is something that should be adopted at Rice.

"The overall objective is to continue the journey toward a safer Rice Hospital," said Maureen Ideker, chief nursing officer.

With dozens of patient safety and quality initiatives being undertaken each year, Rice Hospital already is well on the way toward making its systems safer, she said. "As we look at system design, we try to improve the safety and reliability."

But in a just culture, employee behavior also becomes important, she said.

Hospitals that adopt this philosophy put more emphasis on the fact that even though anyone can make an error, everyone in the hospital, from the medical staff to the housekeeping crew, must be accountable and aware of the risks for harm that exist.

It's normal, for instance, for people to drift away from established procedures such as always double-checking the patient's identification, Ideker said. "Over time you begin to take a little bit of a shortcut."

Or sometimes a human error or lapse will occur, she said. "Even though we don't want them to happen, sometimes they do happen."

These cases might be remedied with a better procedure, or additional training, or changes to the hospital environment to minimize the chances of another similar error.

But sometimes an employee engages in at-risk behavior or even does something that could be considered reckless.

Depending on the situation, sanctions might be warranted, said Dale Hustedt, interim chief executive.

"A lot of it has to do with intent," he said.

For instance, an employee might ignore a policy in order to help a patient, he said. "That may be a violation of the policy but the person did the right thing."

Sometimes health care workers do things that are risky because they don't recognize the risk or because they believe the risk is justified, Ideker said.

"We're just learning more about how to manage behaviors," she said. "The behavior choices can be influenced by management, so management and employees are both accountable. This shift is a big thing and it's not going to happen fast. It can actually take years to change a culture."