PS 203 Lesson 1: A Just Culture Case Study
What should the leaders of a health care system do when a serious adverse event occurs? In this lesson, you’ll learn how a wrong-site surgery occurred at a respected Boston hospital and how the hospital handled it immediately afterward. The lesson will also discuss a range of responses to error, including whether to disclose the mistake and whether to punish the people involved.
Estimated Time of Completion: 15 minutes
Learning Objectives
After completing this lesson, you will be able to:
1. Identify and analyze the range of possible responses to adverse events, including issues around disclosure and punishment.
2. Discuss the challenge of balancing of “no blame” versus professional accountability in a culture of safety.
3. Develop your own ideas and opinions about how best to respond to adverse events.
Contributors
Author(s):
Robert Lloyd, PhD, Vice President, Institute for Healthcare Improvement View Profile
Sandy Murray, MA, Improvement Advisor, CT Concepts View Profile
Lloyd Provost, MS, Improvement Advisor, Associates in Process Improvement View Profile
Editor(s):
Laura Fink, Director, Editorial and Online Learning, Institute for Healthcare Improvement View Profile
Jane Roessner, PhD, Writer, Institute for Healthcare Improvement View Profile
Reviewer(s):
Patricia McGaffigan, RN, MS, CPPS, Vice President, Safety Programs, Institute for Healthcare Improvement View Profile
James Moses, MD, MPH, Chief Quality Officer, Boston Medical Center View Profile
Requirements
You must be a registered IHI.org user to take this lesson.
You must achieve a minimum score of 75% to successfully complete this lesson.