b'LEADERSHIP GUIDE|The FDA has published a number ofof safety with the need for professional guidelines to help manufacturers designaccountability. This culture distinguishesDr. Avillion is an accomplished nursing pro-drug labels, labeling, packaging, and selectbetween human error, at-risk behavior, andfessional development specialist and pub-drug names. To avoid errors and facilitatereckless behavior. A just culture establisheslished healthcare education author. She is safe use of drugs, the FDA recommendszero tolerance for reckless behavior (e.g.the owner of Strategic Nursing Professional that (FDA, 2018b): refusing to perform a surgical time out) ver- Development, a business devoted to helping Oral dosage forms (e.g. tablets) havesus an error made due to consistently poornurses maintain competency and enhance distinct and legible imprint codes sostaffing and unrealistic policy mandates.their professional growth and development. healthcare providers and consumersHuman error or near misses can highlightDr. Avillion earned her doctoral degree in can verify drug product and strength. flawed processes and systems, which shouldadult education and her M.S. from Penn Oral syringes and other dosing devicesbe promptly addressed and correctedState University, along with a BSN from that are co-packaged with a liquid oral(Patient Safety Network, 2018c). Bloomsburg University. She has served in dosage form should be appropriate forSustaining a culture of safety and a justvarious nursing roles over her career in both the doses to be measured. For example,culture can be problematic. It requiresleadership positions and as a bedside clini-errors have been documented when anthe participation of all employees at allcal nurse. She has published extensively and oral syringe is labeled in milligramshierarchical levels to consistently acceptis a frequent presenter at conferences and but the dose is actually prescribed inresponsibility for patient safety. It requiresconventions devoted to the specialty of con-milliliters. organizational leadership to actively sup- tinuing education and nursing professional The package design for various formatsport cultures of safety and just cultures bydevelopment.should be distinct and clearly labeled.soliciting employee concerns and their input For example, topical medicationson problem solutions. Implementation andErin Luckiesh, MSN, RN, CPNP-PC, is should not be packaged in containersmaintenance of these cultures necessitatea pediatric nurse practitioner living in the that resemble those for oral productsthe need for ongoing evaluation of organi- San Francisco Bay Area. Erin graduated or for products administered in thezational effectiveness and willingness tofrom Yale School of Nursing in 2016 where eye, nose (nasal spray), etc. accept required changes for the improve- she completed a masters degree in the pedi-ment of patient safety (Patient Safetyatric specialty. She has had pediatric clini-CULTURE OF SAFETY Network, 2018c). cal experiences at Yale New Haven Hospital No discussion of medication error preven- in New Haven, Connecticut, and at various tion would be complete without address- CONCLUSION pediatric primary care sites in Connecticut, ing the need for a culture of safety, which isEven though there are many variables thatand has worked as a registered nurse in a characterized by (Patient Safety Network,can lead to medication errors and nearpediatric mixed urgent care/primary care 2018c): misses, there are multiple interventionssetting in Maine. Erins clinical experience Acknowledgment of the high-riskthat healthcare professionals and organi- has included pediatric respiratory acute nature of healthcare organizationszational leadership can take to enhancecare, community-based pediatric primary activities. patient safety. All employees, however, havecare, pediatric orthopedics, and pediat-A blame-free environment thata responsibility to promote patient safety.ric epilepsy. Erin was a volunteer at the encourages persons to report errorsA housekeepers attention to spills is just asUCSF Childrens Hospital playroom in San and near misses without having toimportant as accurate medication admin- Francisco for four years and has travelled to worry about reprimand, retaliation, oristration. It is important to ensure that allXian, China, to volunteer at a foster home punishment. employees understand their roles in main- for orphaned infants and young children.Collaboration across ranks and dis- taining safe environments.ciplines to seek solutions to safetyThe Agency for Healthcare Research andREFERENCESproblems. Quality recommends ongoing assessment1.Bodell, M. (2015). 10 rights of medication The organizations commitment toof safety culture and formally measuringadm inistration. Retrieved from https://provide resources to address safetythe effectiveness of the organizations cul- nursingnotes.co.uk/10-rights-of-medi-concerns. ture as it pertains to safety (Patient Safetycation-administration/.Cultures of safety are associated withNetwork, 2018c). Such assessment should2.Centers for Disease Control and reduced error rates and increased abilitiesbe part of all departments quality initia- Prevention (CDC). (2017a). Therapeutic to resolve safety issues before errors occur.tives so that all employees become accus- drug use. Retrieved from https://www.In order to accomplish this, the term justtomed to thinking and reacting in ways thatcdc.gov/nchs/fastats/ drug-use-thera-culture is widely used. A just culture isconstantly assess safety and to feel free topeutic.htm.one that reconciles the no-blame culturepropose solutions to safety problems.n 3.Center for Patient Safety. (2018). 20 LEADERSHIP GUIDE|2020| www.elitecme.com'