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August 2011, Volume 41 Number 8 , p 46 - 48


  • Leslee H. Shepard EdD, MSN, RN, CMSRN


WHEN NURSES are asked to describe their daily practice, the word that always seems to surface is unpredictable. Unfortunately, this unpredictability is one factor that can lead to clinical errors, sometimes fatal ones, and near-misses. New nurses are at even greater risk for making clinical errors.Nurses need additional learning opportunities beyond standard unit orientation and annual educational requirements. Creating a "Just Culture" is one strategy that improves patient safety by encouraging nurses to learn from each others' mistakes.1-3In a Just Culture, staff nurses are encouraged to report all clinical errors and near-misses without fear of repercussions so they can receive corrective feedback and everyone can learn from the experience. This article discusses how to plan and implement this fully transparent process that has patient safety as its primary goal.4,5In a Just Culture, nurses are responsible not only for their own actions but also for giving constructive feedback to their peers. According to Connor and colleagues, this accountability model promotes a balance between learning and personal discipline.4Despite national regulatory agencies' requirements to report errors and near-misses, nurses are reluctant to report events for fear of reprimand.5 Inconsistent reporting behaviors ultimately result in unreliable data, hindering improvement efforts.Constructivism, a theory about learning, suggests that people learn best through interactions and discussions with others. This dialogue allows a person to integrate new information with prior knowledge to facilitate new understanding.6 Through this type of reciprocal learning, nurses can learn about the causes of errors and begin proactive interventions to avoid future errors.Clinical mistakes range from individual errors to system failures. Regardless of the cause of these mistakes, some kind of reporting system must be activated. Although nurses complete incident reports, most nurses never know what corrective

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