NUR 6320 Module 5 Leadership and Accountability Example

The Second Glargine Dose: Just Culture, Individual Accountability and System Repair After a Downtime Medication Error

Student Name

M.S., Nursing Administration Concentration, Thomas Edison State University

NUR-6320: Nursing Administration: Standards and Structures

Mentor Name

Month Day, Year

The Second Glargine Dose: Just Culture, Individual Accountability and System Repair After a Downtime Medication Error

During a four-hour computer downtime on a winter night at our critical access hospital, a swing-bed patient with type 2 diabetes received a second evening dose of insulin glargine. The first dose had been given and charted electronically just before the downtime began; the float nurse who took over the patient used the paper backup medication record, which had been printed earlier in the day and did not show the dose. At 2 a.m., the aide doing rounds noticed the patient was clammy and disoriented, the blood glucose was 41 mg/dL, and the nurse treated the hypoglycemia promptly. The patient recovered fully. This paper analyzes the director of nursing's response, separating the system failures from individual behaviors, applying a just culture approach to accountability, addressing the needs of the staff involved and tying each judgment to a professional or regulatory standard.

Immediate Response and Disclosure

The director's first obligations were to the patient. The house supervisor confirmed the patient was stable, the attending physician was notified, glucose checks were ordered every hour until morning, and the patient and family were told what had happened, that a review had begun and what changes would follow. Honest disclosure is part of the ethical obligations in the nursing administration standards, which call on administrators to advocate for patients and maintain a culture of safety. The event was entered in the hospital's safety reporting system that night by the nurse who gave the dose, and the director reviewed state reporting requirements with the patient safety officer, who determined the event's reporting category under state patient safety law.

What the Review Found

A review led by the patient safety officer and the director, with the nurses involved, found several contributing factors. The downtime procedure required the backup medication record to be printed every four hours, but the print job had failed silently for two days. The nurse handing off the patient said in report that the evening insulin was "done," but the receiving float nurse, assigned from the emergency department, heard it as referring to the bedtime glucose check. The float nurse checked the paper record, saw no glargine documented and gave the dose without calling the previous nurse to confirm. There was no independent double check for long-acting insulin during downtime. Nobody acted recklessly, but several safeguards had failed at once.

Applying Just Culture

A just culture distinguishes among human error, at-risk behavior and reckless behavior and responds differently to each. When the cause is a genuine mistake, such as a misheard word or a missed line, the leader supports the person and repairs whatever made the mistake easy. When the cause is a shortcut whose danger the person underestimated or thought acceptable, the response is coaching, along with removing whatever made the shortcut tempting. Reckless behavior, a conscious disregard of substantial and unjustifiable risk, warrants sanctions. Khatri et al. (2009) argued that health care organizations struggle to move from blame to just cultures when they rely on hierarchical, compliance-based management, and that just cultures are more likely where employees are involved in decisions and human resource practices support learning.

Applying the framework, the miscommunicated handoff was human error. The float nurse's decision to give a high-alert medication during downtime without confirming the prior dose was at-risk behavior, a shortcut many nurses had taken because downtimes were rare and the paper record was usually current. The failed print job was a system failure with no individual cause. The director's responses followed: consolation and involvement in the fix for the handing-off nurse, coaching for the float nurse on verification during downtime, and system repairs. No disciplinary action was taken.

Individual Accountability Within the Standards

Just culture does not remove individual accountability. The state board's standards of nursing conduct oblige every RN to take on only the practice the nurse is prepared and competent for, to document and maintain accurate records and to act to safeguard patients (49 Pa. Code § 21.18). The float nurse was accountable for verifying the patient's insulin status, and the coaching conversation made that explicit, focusing on what verification looks like when the usual system is down. The event did not involve impairment, falsification or a pattern of unsafe practice, which would have required a different response and possibly a report to the board. The director documented the reasoning, so that the decision could be explained if questioned.

Caring for the Staff Involved

The nurses involved were shaken. Scott et al. (2009) described a largely predictable trajectory for clinicians who become second victims after adverse events, moving through stages from chaos and intrusive reflections to restoring personal integrity and, for some, moving on by thriving, merely surviving or dropping out of the profession, and argued that organizations could identify at-risk clinicians early and provide support. The director met with both nurses within a day, arranged peer support through the hospital's employee assistance program, and invited them to help redesign the downtime procedure. Leadership research supports this approach: Cummings et al. (2018) reported that leaders who build relationships tend to have more satisfied and healthier nursing staff than leaders focused only on tasks.

System Repairs and Follow-Up

The practice council, with both nurses participating, adopted four changes. Backup medication records now print automatically every two hours with an alert to the charge nurse if a print fails, and the night charge nurse confirms the print at the start of each shift. High-alert medications, including all insulin, require an independent double check during downtime. Handoff report uses a structured form listing the time of the last dose for each high-alert medication. Downtime drills are held quarterly. The director will report the changes to the quality committee and audit the next three downtimes for compliance.

Six months after the event, the director will report back to the staff on whether the changes are working, including the results of downtime audits and drills. Closing the loop in this way shows that reporting an error leads to improvement rather than blame, which is the behavior a just culture depends on.

References

Cummings, G. G., Tate, K., Lee, S., Wong, C. A., Paananen, T., Micaroni, S. P., & Chatterjee, G. E. (2018). Leadership styles and outcome patterns for the nursing workforce and work environment: A systematic review. International Journal of Nursing Studies, 85, 19-60. https://doi.org/10.1016/j.ijnurstu.2018.04.016

Khatri, N., Brown, G. D., & Hicks, L. L. (2009). From a blame culture to a just culture in health care. Health Care Management Review, 34(4), 312-322. https://doi.org/10.1097/HMR.0b013e3181a3b709

49 Pa. Code § 21.18 (2024). Standards of nursing conduct. https://www.pacodeandbulletin.gov/Display/pacode?file=/secure/pacode/data/049/chapter21/s21.18.html

Scott, S. D., Hirschinger, L. E., Cox, K. R., McCoig, M., Brandt, J., & Hall, L. W. (2009). The natural history of recovery for the healthcare provider "second victim" after adverse patient events. Quality and Safety in Health Care, 18(5), 325-330. https://doi.org/10.1136/qshc.2009.032870