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patient safety in a just culture

Patient Safety Writing Assignment

Patient safety is paramount to Nursing & health care delivery. As nurses we literally hold patient safety in the palm of our hands. However personal responsibility is a good start, it is imperative that as professionals we create a Just Culture of patient safety. The purpose of this assignment is to read, analyze and synthesize the information in the following 3 articles regarding patient safety:

  • The Patient safety chain: Transformational leadership’s effect on patient safety culture, initiatives & outcomes *hard copy given the first day of class
  • ANA Position Statement Just Culture *hard copy given the first day of class
  • To Err is Human
  • View the videos on the Black board LMS

Goal: To understand and be able to demonstrate the nurse’s responsibility in patient safety, reducing medical errors and creating a Just culture.

Objective: the student will:

  • Read the 3 articles
  • Write a 3-5 page narrative demonstrating knowledge of the history of a Just culture and the leadership style most consistent with this concept.
  • Demonstrate an understanding of the 3 classes of human behavior that create predictability in error occurrence by applying one of the classes to a personal incident you experienced note what actually happened in terms of how it was handled and how you felt as a result. (A personal incident that happened to me while taking care of a patient was a patient that was transferred to the ICU from the floor post seizure. They had called a rapid response on the patient due to her seizing and they converted the rapid response into a stroke alert. There is a set protocol for following rapid responses and stroke alert. Upon receiving the patient in the ICU and stabilizing her I decided to look at her labs. The patient’s sodium levels had not been drawn for three day and it was already on the lower range of acceptable limits. I decided to order a Basic Metabolic Panel and draw her blood. When I look at the results an hour later the sodium level was 118 which is what caused the patient to go into a seizure earlier before on the floor. I called the intensivist to let him know of this result and he was upset because he had ordered a BMP to be drawn when the patient was in a rapid response however for some reason the order was canceled when the rapid response was converted into a stroke alert.)
  • Take the same experience and apply the Just Culture approach.
  • Demonstrate knowledge of APA format ( title & reference page, in-text citation, 3-5 page content)

Please find attached rubric as well as articles to support writing.


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