Just Culture Method. Medications
Errors
What is considered the best way to address at-risk behaviors? - answer Removal of
barriers to safe behaviors
How would you describe reckless conduct? - answer Conscious disregard of significant
risk.
Pharmacist Amanda made an error in which she placed prescriptions for two different
patients in the same bag. This happened because she got distracted when trying to do
two things at once: talk on the phone with a prescriber while checking prescriptions.
Which best describes Amanda's behavior that could have led to a patient possibly going
home with another patient's medication? - answer Both human error and at-risk
behavior
What is a principle of the Just Culture model of dealing with errors? - answerAim to
balance between punitive and blame-free responses to errors
A clomiphene prescription was erroneously filled with clomipramine. Reckless behavior
was not involved. In a Just Culture environment, how do you best address the cause of
this error? - answerExamine the dispensing procedures and make necessary changes
to prevent this type of error from occurring again.
What is important to remember when reporting medication errors? - answerReport all
medication errors and close calls.
What is a close call (near miss) in the context of medication errors? - answerAn error
occurs, but is caught before it reaches the patient.
What impact can error reporting have on the healthcare system? - answerDissemination
of nationwide safety alerts
What is the most appropriate response to a patient if an error occurs? - answerI'm sorry
this happened to you.
What can you share with a colleague about the "second victim" of medication errors? -
answerHealthcare providers involved in a med error often have guilt, shame, and self-
doubt.
Errors
What is considered the best way to address at-risk behaviors? - answer Removal of
barriers to safe behaviors
How would you describe reckless conduct? - answer Conscious disregard of significant
risk.
Pharmacist Amanda made an error in which she placed prescriptions for two different
patients in the same bag. This happened because she got distracted when trying to do
two things at once: talk on the phone with a prescriber while checking prescriptions.
Which best describes Amanda's behavior that could have led to a patient possibly going
home with another patient's medication? - answer Both human error and at-risk
behavior
What is a principle of the Just Culture model of dealing with errors? - answerAim to
balance between punitive and blame-free responses to errors
A clomiphene prescription was erroneously filled with clomipramine. Reckless behavior
was not involved. In a Just Culture environment, how do you best address the cause of
this error? - answerExamine the dispensing procedures and make necessary changes
to prevent this type of error from occurring again.
What is important to remember when reporting medication errors? - answerReport all
medication errors and close calls.
What is a close call (near miss) in the context of medication errors? - answerAn error
occurs, but is caught before it reaches the patient.
What impact can error reporting have on the healthcare system? - answerDissemination
of nationwide safety alerts
What is the most appropriate response to a patient if an error occurs? - answerI'm sorry
this happened to you.
What can you share with a colleague about the "second victim" of medication errors? -
answerHealthcare providers involved in a med error often have guilt, shame, and self-
doubt.
