MMHA 6501 Week 8 Just Culture Position Paper Example

Consistent Is Not the Same as Fair: A Just Culture Position on Three Skipped Medication Checks at Maple Terrace

Student Name

Walden University

MMHA 6501: Leadership Within the Healthcare Sector

Instructor Name

Month Day, Year

Consistent Is Not the Same as Fair: A Just Culture Position on Three Skipped Medication Checks at Maple Terrace

Position

A leader who responds to every error the same way is being consistent, not fair. Leadership ethics asks leaders to treat people justly, which is not the same as treating them identically (Northouse, 2021). Fairness requires distinguishing between an honest mistake, a risky habit that has become normal and a conscious choice to disregard a known rule, and responding to each differently. This paper applies that position to three cases from the medication pass at Maple Terrace, the course's composite nursing home, each involving a certified medication aide who skipped the second identification check during the morning medication pass. The facility's procedure requires aides to confirm each resident's identity using two identifiers, a photo on the medication administration record and the resident's name band or verbal confirmation, before giving medications.

The Just Culture Framework

Marx (2001) asked leaders to look past the outcome of an error to the behavior that produced it, and he sorted that behavior into three bins. In the first, a person meant to do the right thing and slipped; the leader's job is to support the person and look hard at whatever in the work set the slip up. In the second, a person chose a shortcut without seeing its danger, usually because colleagues take the same shortcut every day; the leader coaches, and asks what makes the shortcut attractive. In the third, a person saw the danger clearly and went ahead anyway; only there does the leader move to formal accountability. Reason (1997) emphasized that most errors in complex organizations arise from the interaction of individual actions with latent conditions in the system, which is why a just culture looks at both.

Case 1: The Unfamiliar Package

During the morning pass on the short-stay unit, an aide working her second shift at Maple Terrace gave a resident his morning medications. The pharmacy had changed the packaging for that unit the previous week, and the photo on the new medication administration record printout was small and placed differently than on the old format. The aide looked for the photo, did not find it quickly, believed she had confirmed the resident's identity from the room number and the bed position, and moved on. The medications were correct, but she had not completed the two-identifier check.

Sort: human error. She intended to follow the procedure and believed she had. A change in the system, the new printout layout, made the slip more likely, and her unfamiliarity with the facility increased the risk.

Response: console and fix the system. The unit manager should speak with the aide supportively, confirm that she understands the check, and report the printout layout to the pharmacy and the nurse educator so it can be corrected and other new staff warned. Discipline would teach staff to hide slips and would do nothing to prevent the next one. The unit manager should also thank the aide for being candid when asked, since the facility learned about the printout problem only because she described honestly what had happened.

Case 2: The Hall Where the Shortcut Was Normal

On one hall of the long-stay unit, an experienced aide routinely skipped the second identifier for residents she had cared for over many months, reasoning that she knew them by sight. When asked, she said that every aide on the hall did the same, and observation confirmed it. No error had resulted, and the aides believed the risk was negligible.

Sort: at-risk behavior. She made a choice, but she did not see the risk, and the shortcut had become the hall's norm. The risk is real: residents with dementia may sit in another resident's chair, roommates may be similar in appearance, and familiarity is precisely when identification errors are least expected.

Response: coach and remove the incentive. The unit manager should coach the aide and the whole hall, explaining why the check matters even with familiar residents, and should ask why the shortcut developed. If the answer is time pressure during the morning pass, the system needs fixing as well, perhaps by staggering medication times or adjusting assignments. Disciplining one aide for a practice the whole hall shares would be unfair and would leave the norm intact.

Case 3: The Check Skipped After Being Told

An aide who had been coached about the two-identifier check two weeks earlier, after an audit found her skipping it, was observed skipping it again on a busy morning. When the unit manager asked, she said she had decided the check was unnecessary and would continue to skip it when she was behind.

Sort: reckless behavior. She knew the rule and the reason for it, had been coached, and consciously chose to disregard a substantial risk to residents for her own convenience.

Response: accountability through the established process. The unit manager should refer the matter to the director of nursing and human resources under Maple Terrace's progressive discipline policy. The same just culture framework that protected the aides in the first two cases requires accountability here; a culture that never holds anyone accountable is not just, and staff who follow procedures would rightly see it as unfair.

The Leader's Duty to Fix the System

Just culture is sometimes misread as a way to decide who to discipline. Its larger demand falls on leaders. In two of the three cases, the system contributed: a confusing printout and a medication pass that left too little time. If leaders console the first aide and coach the second without fixing those conditions, they will see the same errors again, and staff will learn that just culture is a set of words rather than a practice. Maple Terrace's leaders should therefore report each case's system finding to the quality committee, track whether it was fixed, and tell staff what changed. Treating errors fairly means treating the system as accountable as well as the individual (Reason, 1997), and the visible repair of a confusing form does more to build trust in reporting than any policy statement.

References

Marx, D. (2001). Patient safety and the "just culture": A primer for health care executives. Columbia University.

Northouse, P. G. (2021). Leadership: Theory and practice (9th ed.). Sage.

Reason, J. (1997). Managing the risks of organizational accidents. Ashgate.