WHA Just Culture
Scenario One - Answer Key
SCENARIO ONE
Joe was a veteran medical technologist in the laboratory. His co-workers noticed that he was starting to cut corners and not follow all procedures.
Staff communicated their concerns to the manager, however no action was taken. A cardiac patient was admitted to the ED and a brand new
phlebotomist was sent to collect the blood samples. The new phlebotomist drew the blood samples at a site above a running IV with potassium
(which is bad because you are basically drawing IV fluid which will make the lab tests wrong). Joe ran the samples in the chemistry lab and got a
panic level high potassium, which he called to the ED. Joe did not follow the standard procedure of requesting a second blood specimen to verify
the panic level test result. The ED treated the patient for high potassium and the treatment caused the patient to suffer a cardiac arrest.
What would you need to know from the event investigation?
New Phlebotomist
o Was he/she aware of the blood draw procedure?
o What initial training/orientation did he/she receive?
o Does protocol stipulate when a new staff person is able to complete a blood draw without supervision?
Joe (Veteran Med Tech)
o When did he receive training on the second blood draw protocol?
o What is causing Joe to drift?
Emergency Department Staff
o Was ED staff aware of staff policies on ED draws, specifically when to request a re-draw?
Management
o Why were no actions taken with Joe based previously shared concerns by staff?
o Have similar concerns been brought up for other staff?
System Factors
o What generally happens, what should happen?
o How often are blood draw policies followed?
o Is similar drift noticed with other staff?
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WHA Just Culture
Scenario One - Answer Key
Were any duties breached in this scenario? If yes, which?
First – determine if the focus will be on Joe or the new phlebotomist – Do you have enough information on each?
o Duty to avoid causing unjustifiable risk or harm - Joe
o Duty to follow a procedural rule – Joe
o Duty to follow a procedural rule – New Phlebotomist
Walking through the algorithm
While the scenario does include a reference to missteps the new phlebotomist took, the scenario does not provide enough information regarding
new hire training to be able to walk this through the algorithm. Any harm caused would be an indirect factor since Joe was responsible for the
testing.
Duty to Avoid Causing Unjustifiable Risk or Harm –Joe
Was it the employee’s purpose to cause harm? No Did the employee knowingly cause harm No Did the behavior represent a substantial
and unjustifiable risk Yes (drift) Did the employee consciously disregard this substantial and unjustified risk? No (because he didn’t see it as
a risk) Should the employee have known they were taking a substantial and unjustifiable risk Yes Did the employee choose the behavior
Yes Coach employee and conduct at-risk behavior investigation
Duty to Follow a Procedural Rule – Joe
Was the duty to follow a rule known to the employee Yes Was it possible to follow the rule Yes Did the employee knowingly violate the
rule Yes Did the social benefit exceed the risk No  Did the employee have a good faith but mistaken belief that the violation was
insignificant or justified? Yes Coach the employee and conduct at-risk behavior investigation.
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WHA Just Culture
Scenario One - Answer Key
What would be your assessment using the algorithm?
o At-risk behavior for Joe
What action would you take based on your assessment?
o Coach Joe and conduct at-risk behavior investigation
o Address why staff concerns were not addressed by Joe’s manager.
o Assess whether drift has been noted with other staff; how much this has become the system “norm”
o Re-assess current training protocols for new/existing staff; how often these are reviewed & whether there is annual re-training.
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