A nurse receives a verbal order which was understood to be for avert 6. the physician actually ordered antivert 25 mg daily. the
patient is also taking prozac®/sarafem® (fluoxetine), which when taken with avert can be life threatening. the patient's condition stabilizes and an interdisciplinary team meets to perform a root cause analysis hoping to learn from the mistake. the nurse was part of the group formed to help identify ways the system could be changed to prevent similar errors. this situation describes:
This situation describes JUST CULTURE. JUST CULTURE is a concept that is used in health care to improve patients' safety. The concept involves examination and analysis of medical errors made by medical practitioners in the course of their duties in order to prevent such occurrence in the future.<span />
