# A nurse manager is discussing patient safety culture with the unit team after a medication error reached the client but caused no harm. According to the principles of Just Culture and never-event reporting, which actions should the manager take? Select all that apply.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=364797&lang=en  
> language: en  
> subject: Performance Improvement  
> category: MOC

## Question

A nurse manager is discussing patient safety culture with the unit team after a medication error reached the client but caused no harm. According to the principles of Just Culture and never-event reporting, which actions should the manager take? Select all that apply.

1

Review system safeguards and update policies as indicated

2

Notify the client and family per facility disclosure policy

3

Counsel the involved nurse to determine whether the behavior was human error, at-risk, or reckless

4

Submit a non-punitive incident report focused on system factors

5

Conduct a root cause analysis with the involved team

6

Suspend the involved nurse pending investigation regardless of the behavior pattern

## Explanation

Just Culture distinguishes among human error (console), at-risk behavior (coach), and reckless behavior (discipline). System-focused, non-punitive reporting plus root cause analysis, transparent disclosure to the client, behavior-based individual counseling, and policy update form the standard response. Automatic suspension regardless of behavior is punitive and contrary to Just Culture, which discourages reporting and worsens patient safety.

## In-depth explanation

Clinical Judgment
Just Culture three behavior categories: human error → console; at-risk → coach; reckless → discipline. Reporting culture should be non-punitive for system and human error. Disclosure to client and family is mandated by Joint Commission NPSG. Root cause analysis (RCA) targets system fixes, not blame.

Memory Tip
Just Culture: Console + Coach + Discipline. RCA + Disclose + Update.

KR vs US
Joint Commission Sentinel Event Policy and Korean Patient Safety Act (2016) both require reporting, RCA, and transparent disclosure. Korean tertiary hospitals operate dedicated patient safety officers similar to US hospitals.

## Clinical scenario

Clinical Practice Guide
Just Culture algorithm (Marx 2001):
- Human error: inadvertent slip or lapse → console, redesign system
- At-risk behavior: drift from safe practice without recognizing risk → coach, increase situational awareness
- Reckless behavior: conscious disregard of substantial risk → discipline

Joint Commission Sentinel Event response:
1. Stabilize and protect the client
2. Disclose to client and family within 24 hours
3. File non-punitive incident report
4. Root cause analysis within 45 days
5. Action plan with timelines and accountable owners
6. Monitor effectiveness at 6 and 12 months

Caution
Never events (CMS list) include wrong-site surgery, retained foreign object, fall with injury, Stage 3-4 pressure injury. CMS does not reimburse the additional care tied to a never event, and many states require public reporting.

## Key concepts

- **Just Culture** — Marx-developed safety culture model that distinguishes human error, at-risk behavior, and reckless behavior. Drives non-punitive reporting and supports continuous improvement. Adopted by The Joint Commission, ANA, and Korean Patient Safety Act.
- **Root cause analysis (RCA)** — Structured retrospective process that identifies system contributors to an adverse event. Multidisciplinary team uses tools such as fishbone diagram or 5-Whys. Output is a corrective action plan with measurable goals. Required by Joint Commission within 45 days of a sentinel event.
- **Never event** — CMS-defined adverse event that should never occur and is largely preventable. Examples: wrong-site surgery, retained foreign object, Stage 3-4 hospital-acquired pressure injury, severe medication error. Many state laws and the CMS Hospital-Acquired Conditions program penalize these events.

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