Professional Documents
Culture Documents
Near Misses
Reportable or Ignorable Mistakes
Lycia L. Harris
Jacksonville State University
November 15, 2012
The Situation
The rules were in place by the organization. The employee just did not
follow protocol. FMEA can not be used, because this incident was
never reported.
Nurse Pat was the second victim because the organization that she
worked for created and environment of blame, to which she was
afraid that being honest would cause her to loose her job or be
suspended. Also, if the organization found out this near miss
occurred and was not reported, even more consequences would
follow.
In a Just Culture, one person is not blamed, but the system as a
whole is evaluated to prevent these kind of errors from occurring.
As a nurse manager, this writer would stress the importance of
integrity as it pertained to patient care and the importance of filling
out proper reports so events like this could be followed and new
methods developed.
References:
Institute for Healthcare
Improvement(2010). Clinical teaching
strategies in nursing (3rd edition) . New
York: Springer.
Marx,D. (2007). Patient Safety and the
Just Culture. Retrieved from
Http://www.health.state.ny.us/professional
patients/patient_safety
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