Communication
A dynamic where less powerful people manage unequal power distributions
What is "power distance"?
This safety theorist was the author of "just culture" during the late 1990s to describe a mood of trust where people feel open to share essential, safety information and can distinguish between safe and unsafe behaviors.
Who is James Reason?
Organizations should monitor 3 types of metrics: leading indicators, real-time indicators and lagging indicators
What are safety related metrics?
This prompts investigators to examine causal factors to look for all possible causes of a harm event
What is a Root Cause Analysis?
When the attending did not respond to the nurse's request for clarity about a vacuum extraction during delivery, she repeated her concern using CUS
What is an example of the "Two-Challenge," rule?
Complete, clear, brief, timely and respectful
What are standards of effective communication?
This tool is used to determine when an error occurs, if it is a system error or if the person intended to do harm
What is the Just Culture decision making algorithm?
This is one indicator to determine if a Serious Safety Event has occurred
What is determination if standard of care was met?
This analysis can be used when multiple failures have occurred
What is a common cause analysis?
Human factors, communication breakdown, poor teamwork
What are the top 3 contributors to sentinel events?
Honest, collaborative, reflective and able to experiment
What are high functioning teams?
This involves systems thinking where after an incident the focus is on what went wrong and how to improve rather than blaming an individual
What is Just culture?
Patient willingness to recommend, operating margin, employee engagement scores
What are leading indicators?
Review of safety issues on the unit level over the past 24 hours and escalating issues requiring more attention up the chain of command
What is a tiered (or SMESS) huddle?
Hierarchy, fear of being wrong, inexperience and fear of repercussions
What are barriers to speaking up?
Role play, feedback and coaching on interactions
What are ways to improve communication?
Who can make a difference teaching and improving processes in a Just Culture?
All of us
Management systems that monitor performance, identify deviations and resolve problems
What is a control loop?
Sharing of a "good catch," where safety skills have been applied and keep the patient safe
What is a safety story?
The state of knowing what's going on around you
What is Situational Awareness?
A verbal communication tool used to keep the group apprised of changes in a procedure
What are call outs?
This is what we learn from to get better in a Just Culture
Mistakes
Performance Improvement project involving front line staff from Admissions, ED and EMS evaluating the patient triage process
ED triage Process Improvement, started on 01/09/26
An OSHA safety standard where workers disconnect and lock defective equipment with a tag that must be removed before using again
What is lockout/tagout?
A team outcome that results from each team member maintaining situational awareness and communicating to ensure all team members are on the same page
What is a Shared Mental Model?