Just Culture

Fear of Punitive Response to Hospital Errors

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Hospitals are developing a culture of safety in which open discussion and reporting about adverse events, mistakes, disruptive behavior and unsafe conditions is applauded rather than punished. However, a February Agency for Healthcare Research and Quality survey showed that healthcare professionals working in hospitals believe hospitals are still more interested in a punitive system and enforcing hierarchy rather than creating a culture of safety and open communication. About 54 percent said that when adverse events are reported, “it feels like the person is being written up, not the problem,” and nearly 67 percent said they are concerned that mistakes are being held in their personnel files. Less than 50 percent believe they are free to question decisions or actions of superiors. The survey also indicates that 20 percent of hospitals have improved in terms of non-punitive response to errors, while 16 percent have worsened.

From Fear of Punitive Response to Hospital Errors Lingers
American Medical News (02/20/12) O’Reilly, Kevin B.

Hospitals face fines for overdose, leaving sponge in patient

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L.A. NOW – Southern California

The California Department of Public Health issued $850,000 in fines against 14 hospitals for medical errors that caused — or were likely to cause — serious injury or death to patients, officials announced Thursday.

Three of the hospitals — Henry Mayo Newhall Memorial Hospital, Los Angeles County-USC Medical Center and Torrance Memorial Medical Center — were in Los Angeles County.

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MOCPS Hosts Table at Health Literacy Missouri – Sorrel King reinforces our mission

    Posted in CUSP, Events, Just Culture, Media, Medical Error, Patient Safety, Sorrel King    |    Comments Off

The MOCPS was pleased to host a table at the October 5th Health Literacy Missouri awards luncheon.  Keynote, Sorrel King, is always a pleasure to hear, although the story of her 18 month old daughter, Josie’s, death from failures in the health care system is heart wrenching.  Read More

5 Current Trends in Patient Safety (from ASC Review)

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Article from GE Healthcare Performance Solutions on current safety trends worth reading:  PSOs, Just Culture, review of policies and procedures, use of simulation, and reduction of variance.  PSOs is listed as the #1 trend, identified as the only way health care providers can share stories and learning without fear of litigation “because big improvements in safety are about learning.”

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Patients and Caregivers are Victims of Medical Error

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Kimberly Hiatt, a nurse involved in a medical error that resulted in the death of an 8 month old, committed suicide.  This important story highlights the many victims of medical error, the importance of a just culture, and the need for resources to help the second victim.

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Sneak Peek! EMS Just Culture Movie Trailer!

    Posted in Center Info, David Marx, EMS PSO, Just Culture, On The Scene Video    |    Comments Off

The Center is proud to announce its participation in Outcome Engineering’s soon to be released video, On The Scene, a Just Culture training film for EMS.  We assisted with general content for script development and participated in the panel discussion filming segment. Also including the Missouri Ambulance Association, the 30 minute film portrays rich character-driven scenarios from the EMS working environment that are easy to relate to and designed to engage the attention of staff member.  Check out the trailer!

MAA’s significant role in this production included their technical expertise; along with CoxHealth EMS, St. Johns EMS, Hammons Life Line Air Ambulance and Ozark Fire Department all of which donated equipment, time, locations, staff as extras and more.

Coming soon – the Center’s Next PPLT Module!

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Friday, June 10th is the last day to register for the informational “kick-off” call for the Center’s Second PPLT Module: CUSP Communication & Teamwork Tools!
We are excited to offer an audio version of our recent informational call to kick off CUSP Communication & Teamwork Tools! [And be on the lookout for consistent audio posts in the future]

The deadline to register for CUSP Communication and Teamwork Tools is Friday, June 10th.
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The Center’s Patient Safety Tele-Forum with Host, Nick Haines from KCPT-TV

    Posted in Accountable Care, AHRQ, Center Info, David Marx, Department of Health and Human Services, Diane Cousins, HHS, Judy Baker, Just Culture, Media, Prevention, Sean Berenholz    |    Comments Off

Nick Haines

The below Tele-Forum segments, hosted by KCPT’s Nick Haines, include patient safety experts, Judy Baker, Dr. Sean Berenholz, David Marx, Becky Miller and Diane Cousins, whose brief and information-packed discussions trigger a wide variety of potential news stories.

A consistent and key goal for the Center is patient safety awareness within the health care industry, for the media and the general public.  We intensify our awareness and educational efforts each year in the month of April to further increase the use of patient safety language and cultural practices professionally and publicly.

Learn More.

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