# Situation: A nurse works on the pediatric ward of a tertiary hospital, where children weighing 8 to 30 kg receive most of their medications from the nursing staff. The unit is reviewing its medication safety practices. A nurse on the ward has stopped doing the required independent double check before giving insulin to children. She says the doses are small and that other nurses also skip it when the ward is busy. No child has been harmed. Under a just culture, how should the manager classify and respond to this behavior?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=629461  
> language: ko  
> subject: Nursing Practice II — Maternal and Child Health Nursing

## 문제

Situation: A nurse works on the pediatric ward of a tertiary hospital, where children weighing 8 to 30 kg receive most of their medications from the nursing staff. The unit is reviewing its medication safety practices.

A nurse on the ward has stopped doing the required independent double check before giving insulin to children. She says the doses are small and that other nurses also skip it when the ward is busy. No child has been harmed. Under a just culture, how should the manager classify and respond to this behavior?

## 보기

1. Human error, so the manager consoles her and fixes the system
2. At-risk behavior, so the manager coaches her about the shortcut **✔ 정답**
3. Reckless behavior, so the manager takes disciplinary action
4. A near miss, so the manager files a report and takes no other step

**정답: 2**

## 해설

Just culture separates three kinds of behavior. A human error is an inadvertent slip and is met with consolation and system fixes; at-risk behavior is a drift into a shortcut whose risk is not recognized and is met with coaching; reckless behavior is conscious disregard of a substantial risk and warrants discipline. Skipping a required double check because it seems unnecessary, as others also do, is at-risk behavior.

## 심화 해설

Just culture classification of the behavior

The nurse’s decision to skip the required independent double check for insulin is best classified as at-risk behavior. In a just culture framework, this category describes a situation where a clinician drifts into a shortcut without fully recognizing the potential for harm. The nurse rationalizes the omission by pointing to the small dose and the fact that other nurses also skip the check when the unit is busy. That normalization of deviance is the hallmark of at-risk behavior: the unsafe practice becomes accepted as routine, and the individual does not consciously intend to cause harm .

At-risk behavior is managed through coaching rather than punishment because the clinician needs to understand why the shortcut is dangerous and how it can drift into a serious error. The manager should sit with the nurse, review the purpose of the independent double check for high-alert medications such as insulin, and reinforce the expectation that the check must be performed every time regardless of dose or workload. Coaching focuses on changing the individual’s perception of risk and restoring adherence to the safety rule.

| Behavior type | Definition | Manager response |
| --- | --- | --- |
| Human error | Inadvertent slip or lapse despite intending to follow the rule | Console the nurse; examine and fix system factors |
| At-risk behavior | Drift into a shortcut without recognizing the risk; often normalized by the team | Coach the nurse; increase awareness of risk and reinforce the rule |
| Reckless behavior | Conscious disregard of a substantial and unjustifiable risk | Disciplinary action; possible referral or restriction |

Watch out! The fact that no child has been harmed does not change the classification. Just culture looks at the choice the nurse made and the risk awareness at the time, not the outcome. A near miss is an event category, not a behavior category, so option 4 confuses the two.

Key point! The presence of a unit culture where “other nurses also skip it” is a strong signal of at-risk behavior. It indicates a systemic drift, but the immediate response to the individual nurse remains coaching, while the manager should also examine why the shortcut became normalized across the team .

Why the independent double check matters for insulin

Insulin is a high-alert medication. Even small dose errors can produce severe hypoglycemia, seizures, or neurologic injury in a child weighing 8–30 kg. The independent double check is designed to catch wrong-dose, wrong-type, or wrong-time errors before administration. When a nurse skips the check, she removes a critical barrier that exists precisely because insulin errors are disproportionately harmful .

Systematic review evidence shows that nurses commonly omit double checks when clinical demands compete, and the check is often not performed independently even when it is done. Workload, time pressure, and the belief that the dose is too small to matter are recurring reasons for non-adherence . These findings align with the scenario: the nurse perceives the double check as unnecessary for small doses and follows the unit’s informal drift.

Coaching as the just culture response

Coaching is not a soft option. It is a targeted intervention that addresses the gap in risk perception. The manager should:

- Clarify that insulin is a high-alert medication where a double check is mandatory regardless of dose.

- Explore the nurse’s reasoning for skipping the check and correct the misconception that small doses are inherently safe.

- Discuss the normalization of deviance on the unit and the nurse’s role in resisting that drift.

- Set a clear expectation for future adherence and follow up to confirm the behavior has changed.

This approach preserves accountability while recognizing that the nurse did not act with intent to harm. It also opens the door to system-level review, such as examining staffing, workload, and whether the double-check policy is practical and supported .

If the same nurse continues to skip the double check after coaching, the behavior may then be reclassified as reckless, because the risk is now known and consciously disregarded. That escalation is consistent with just culture principles: repeated at-risk behavior after education signals a different level of accountability.

Why the other options are incorrect

Option 1 mislabels the behavior as human error. A human error is an unintentional slip, such as accidentally drawing up the wrong dose despite intending to follow the protocol. Here the nurse made a deliberate choice to omit the check, so consolation and system fixes alone would not address the behavioral drift.

Option 3 over-classifies the behavior as reckless. Recklessness requires conscious disregard of a substantial risk. The nurse’s justification suggests she does not perceive the risk as substantial; she believes the small dose and common practice make the check unnecessary. That lack of risk awareness places the behavior in the at-risk category, which calls for coaching before discipline.

Option 4 confuses an event classification with a behavior classification. A near miss is an event that could have caused harm but did not. The scenario describes a behavioral choice, not a specific medication event. Filing a report and taking no other step would ignore the unsafe practice and allow the drift to continue .

## 임상 시나리오

Just Culture Response to Skipped Insulin Double CheckCoaching for at-risk behavior in pediatric medication safety
When a nurse skips a required independent double check for insulin because the dose seems small and others also skip it, classify this as at-risk behavior. The key feature is normalization of deviance: the shortcut becomes accepted as routine without intent to harm.

The manager should coach the nurse, not punish. Review why insulin is a high-alert medication and reinforce that the double check must occur every time, regardless of dose or workload.

CautionDo not classify repeated, normalized shortcuts as simple human error. If the nurse clearly understood the risk and still chose to skip the check, consider reckless behavior and disciplinary review.

## 핵심 개념

- **Just culture** — A safety framework that distinguishes human error, at-risk behavior, and reckless behavior to match the response to the intent and risk awareness.
- **At-risk behavior** — Drifting into a shortcut without recognizing the risk, often normalized within a team; managed with coaching.
- **Normalization of deviance** — Gradual acceptance of unsafe practices as routine because no immediate harm occurs.
- **Independent double check** — A second clinician separately verifies a high-alert medication order, dose, and preparation before administration.
- **High-alert medication** — A drug such as insulin that carries a heightened risk of significant patient harm when used in error.

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