Improve the quality and safety of patient care in your facility by creating a just culture and developing a high reliable organization. The resources provided in this toolkit provide articles, videos and other resources to assist in exploring and developing these concepts.
Safer Healthcare, an organization that implements high reliability programming and training programs for high risk-organizations, including clinical units, air ambulance operations, and health care systems, worked in tandem with the AORN Foundation in implementing this project and creating the content for this tool kit. The resources provided are examples of team building exercises and communication tools perioperative nurses can utilize in their practice such as ISBAR handoff tools, Briefing and Debriefing checklist.
Healthcare organizations striving to achieve High Reliability navigate the complex and dynamic conditions faced in the Perioperative department in a nearly error free manner. When health care teams work well together, threats and errors can be recognized, prioritized, and managed before an adverse outcome becomes a reality. A culture of safety will not occur without committed and effective leadership at all levels of an organization from the board room to the bedside. This toolkit will provide the tools necessary to promote a practice environment of safety.
Human Factors in Health Tool Kit Components (PDF)
- Introduction: Team Training Objectives
- Why Team Training Using Human Factors?
- Teamwork in the OR
- Getting Started: Steering Committee Planning
- Identifying Program Champions
- The Importance of Physician Involvement
- Effective Communication: The Foundation for Good Teamwork
- Team Briefing Model
- Briefings and Debriefings Checklists
- Situational Awareness: The Ability to Know What is Going on Around You
You need the appropriate tools to implement a just culture at your facility. Implement a just culture by including the following tools:
- Just Culture Reason Algorithm (PDF) provides a six step decision tree that will help you determine accountability when an error, near miss or unsafe act occurs.
- The Just Culture Scenarios (PDF) were created to assist in understanding the concepts of a just culture and the behavioral concepts of human error, negligence, intentional rule violations and reckless conduct.
- The Just Culture Bibliography (PDF) contains numerous articles to expand your understanding of the just culture concept.
AORN Position Statements
View the following AORN Position Statements:
- Patient Safety (PDF)
- Criminalization of Human Errors in the Perioperative Setting (PDF)
- Healthy Perioperative Practice Environment (PDF)
Related External Links
Educate your institution and team. Have managers and all staff that are important to implementing a just culture at your institution review the following links.
- Fair and Just Culture, Team Behavior and Leadership Engagement: The Tools to Achieve High Reliability
- From a Blame Culture to a Just Culture in Health Care
- ANA Position Statement on Just Culture Concept
- National Quality Measures Clearinghouse
- CAHPS: Surveys and Tools to Advance Patient-Centered Care
- ISMP: Just Culture and Its Critical Link to Patient Safety (Part I) - May 17, 2012
- ISMP: Just Culture and Its Critical Link to Patient Safety (Part II) - July 12, 2012
- Pennsylvania Patient Safety Advisory - Gap Assessment of Hospitals' Adoption of the Just Culture Principles - December 2011
- Culture of Safety - ECRI Institute
- Promoting a Culture of Safety: Use of the Hospital Survey on Patient Safety Culture in Critical Access Hospitals
- ISMP: Dr. Leape and Colleagues Present a Compelling Call to Action to Establish a Culture of Respect – June 14, 2012
- AHRQ CUSP Tool Kit
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