# Situation: The adult medical ward of a tertiary hospital reviews its medication safety events. At 05:45, a nurse preparing a 06:00 flush for a 67-year-old man with heart failure picks up a vial of concentrated potassium chloride instead of sodium chloride 0.9%, which is stored in the next bin. The barcode scanner rejects the vial before any drug is drawn up, and the nurse gives the correct flush. Two weeks later, another nurse on the ward gives a scheduled dose of insulin without the independent double check that ward policy requires. The nurse explains that the second nurse was busy and that the check is "usually skipped on nights." The client is not harmed. Using just culture principles, how should the nurse manager respond?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=629759  
> language: ko  
> subject: Nursing Practice III — Care of Clients with Problems in Surgery, Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations

## 문제

Situation: The adult medical ward of a tertiary hospital reviews its medication safety events. At 05:45, a nurse preparing a 06:00 flush for a 67-year-old man with heart failure picks up a vial of concentrated potassium chloride instead of sodium chloride 0.9%, which is stored in the next bin. The barcode scanner rejects the vial before any drug is drawn up, and the nurse gives the correct flush.

Two weeks later, another nurse on the ward gives a scheduled dose of insulin without the independent double check that ward policy requires. The nurse explains that the second nurse was busy and that the check is "usually skipped on nights." The client is not harmed. Using just culture principles, how should the nurse manager respond?

## 보기

1. Start disciplinary action for knowingly breaking the policy
2. Close the report without action, since no harm resulted
3. Console the nurse, since skipping the check was an honest slip
4. Coach the nurse and remove what encourages skipping the check **✔ 정답**

**정답: 4**

## 해설

Just culture responds to the behavior, not the outcome. Skipping a required check because it has become a normal shortcut on nights is at-risk behavior: a drift whose risk the nurse does not recognize. The response is to coach the nurse and remove the incentives for the shortcut (for example, workload that leaves no second nurse available). Consoling fits an inadvertent slip, and discipline fits reckless disregard of a known substantial risk.

## 심화 해설

Just culture and the two medication events

The first event is a near miss caught by technology. The nurse reached for the wrong vial, but the barcode scanner rejected it before any drug was drawn up. In a just culture framework, this is an inadvertent human error or a system-influenced slip. The appropriate response is not punishment, but a review of why two look-alike vials were stored in adjacent bins. The second event is different. The nurse knowingly skipped a required independent double check because it was “usually skipped on nights.” That is not an accidental slip. It is at-risk behavior: a deliberate shortcut that has become normalized on the unit, and the nurse does not fully recognize the risk created by that drift.

Just culture responds to the behavior, not the patient outcome. No harm occurred in either case, but that does not mean the second event should be closed without action. A harm-free outcome does not make an unsafe practice acceptable. Conversely, the nurse does not need consolation as if this were an honest slip, because the check was skipped intentionally. Discipline is also inappropriate. Reckless behavior means the nurse understood a substantial and unjustifiable risk and chose to ignore it. Here, the nurse believed the shortcut was normal and low-risk, which is the defining feature of at-risk behavior.

Key point! The correct response to at-risk behavior is coaching plus system redesign. The nurse manager should help the nurse see why the independent double check matters, and simultaneously remove the conditions that make skipping it attractive—such as night staffing that leaves no second nurse readily available.

| Behavior type | Example | Just culture response |
| --- | --- | --- |
| Human error (inadvertent slip) | Picking the wrong vial without realizing it | Console, examine system factors |
| At-risk behavior (drift, normalized shortcut) | Skipping a double check because “everyone does it on nights” | Coach and remove incentives for the shortcut |
| Reckless behavior (conscious disregard of substantial risk) | Deliberately ignoring a known high-risk safeguard | Disciplinary action |

The systematic review by Zhao et al. supports this distinction. It found that nurses’ adherence to double-checking is inconsistent, and that checks are often omitted when clinical demands compete or when the practice is not performed independently [1]. In other words, skipping the check is frequently a systems problem—staffing, workload, and workflow design—not simply an individual moral failure. That is why coaching alone is insufficient. The manager must also address the workload or staffing pattern that makes the shortcut feel necessary.

The emotional dimension is also relevant. Gharaibeh et al. describe how medication errors can produce fear, silence, and moral injury in nurses, especially when the response is punitive . A manager who responds to the insulin event with discipline would likely deepen that silence. Nurses would become less willing to report future near misses or shortcuts. The goal of just culture is to keep reporting open so that system weaknesses become visible. Coaching the nurse while fixing the underlying system condition preserves that openness.

Rutledge et al. identified fear of punishment and fear of being blamed as major barriers to medication error reporting among hospital nurses . If the nurse manager disciplines the nurse for skipping the check, the message to the rest of the ward is that admitting shortcuts leads to punishment. That drives the behavior underground. The safer response is to treat the skipped check as a signal that the ward’s night workflow does not reliably support the policy. The manager should ask why the second nurse was unavailable and whether the staffing model can be adjusted.

Guntschnig et al. reinforce the systems approach. Their analysis of medication error reports found that root causes are typically system-level, and that sustainable improvement requires addressing those system conditions rather than focusing on individual blame . The potassium chloride near miss and the skipped insulin double check both point to system vulnerabilities: look-alike storage in the first case, and a night workflow that makes the double check impractical in the second. A just culture manager treats both as opportunities to harden the system.

Watch out! Do not confuse “no harm” with “no problem.” The insulin event did not injure the client, but the unsafe practice remains. Closing the report without action would allow the drift to continue until it eventually reaches a client who is harmed.

The nurse manager should coach the nurse to recognize the risk of the shortcut, and simultaneously remove the system incentives—such as inadequate night staffing—that encourage skipping the check. This is the response that fits at-risk behavior in a just culture. It is neither punishment nor consolation, and it does not ignore the event simply because the outcome was benign.References (research sources)

- [1]Nurses' Adherence to Double-Checking: A Systematic Review of Influencing Factors, Improvement Strategies, and Their Effectiveness.Meta-analysis/systematic reviewZhao J, Liu H, Shan A, Peng Y, Or CKL. (2026) · DOI: 10.1111/inr.70179

## 임상 시나리오

Just Culture Response to Skipped Double CheckCoach the nurse and redesign the system, not discipline or console
When a required independent double check is skipped because it is usually skipped on nights, the behavior is at-risk behavior, not an honest slip or reckless disregard. The correct response is coaching plus system redesign.

The nurse manager should help the nurse recognize the risk created by the shortcut and remove the incentives that encourage it, such as night staffing that leaves no second nurse available for the check.

CautionDo not close the report just because no harm occurred. Just culture responds to the behavior, not the outcome. A harm-free event can still reveal an unsafe normalized practice.

## 핵심 개념

- **Just culture** — A safety framework that responds to the behavior (human error, at-risk behavior, reckless behavior) rather than the patient outcome, balancing accountability with system improvement.
- **At-risk behavior** — A deliberate deviation from a rule or procedure where the person does not fully recognize the risk created, often due to normalization of deviance. Managed with coaching and removing system incentives for the shortcut.
- **Reckless behavior** — Conscious disregard of a substantial and unjustifiable risk. Managed with disciplinary action.
- **Inadvertent human error** — An unintentional slip, lapse, or mistake. Managed with consolation and system review.
- **Normalization of deviance** — The gradual acceptance of unsafe shortcuts as normal practice when they repeatedly occur without immediate harm.

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