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Strategy Submission

OB Case Studies for Application of QSEN Safety Competencies: Examination of the Concept of a ‘Just Culture’ through Root Cause Analysis


Sue Mahley



Assistant Professor of Nursing



Research College of Nursing


Competency Categories:


Learner Level(s):

Pre-Licensure BSN

Learner Setting(s):


Strategy Type:

Case Studies

Learning Objectives:

Following implementation of this strategy, the student nurse will:
  1. Describe factors that create a culture of safety (such as open communication strategies and organizational error reporting systems).
  2. Describe processes used in understanding causes of error and allocation of responsibility and accountability (such as root cause analysis).
  3. Participate appropriately in analyzing errors and designing system improvements.
  4. Engage in root cause analysis rather than blaming when errors or near misses occur.
  5. Value vigilance and monitoring (even of own performance of care activities) by patients, families, and other members of the health care team.
  6. Value own role in preventing errors.

Strategy Overview:

Background of Strategy: Considering the high risk stakes and high costs of obstetrical care and that many deaths attributable to human error may be potentially preventable, the Maternity Nursing classroom or clinical sitting (clinical conference)  provide a forum that is ripe for application of the QSEN Safety Competencies. This strategy focuses on promoting a culture of safety and the role of root cause analysis. Implementation of Strategy: To challenge senior nursing students in their Maternity Nursing Course to embrace the concept of just culture, an obstetric case study is presented in which patient safety is jeopardized. (Three sample case studies are provided in the attachments.)Students are divided into teams to review the timeline of events of the same case study. As the investigative team, students must decide on clear roles and methodologies in the analysis of findings and identification of root cause (of the patient safety problem). A root cause analysis flow-sheet is provided to the teams for a systematic approach. Determination of root cause is followed by devising a plan for corrective action. Students utilize a just culture algorithm to ensure that appropriate corrective actions are implemented. Facilitation of effective channels of communication is reflected in their plans. Use of course textbooks and electronic resources are encouraged in order to research system policies and standards of practice (such as AWHONN and ACOG). System weaknesses are evaluated in relation to individual healthcare provider performance. Students gain not only an understanding of maternity care risks but also of health care system policies and practices. The concept of a ‘just culture’ is brought to life through student participation resulting in increased awareness, understanding and appreciation of the complexities of the health care system.  Groups share their findings with all participants at the culmination of the activity.

Submitted Materials:

Additional Materials:

Evaluation Description:

A survey was used to evaluate student response to this teaching strategy. By self-report, students in the first participating class (n=50) ‘agreed’ to ‘strongly agreed’ to an increased understanding of root cause analysis (92%) as well as increased awareness and appreciation of the complexities of the health care system when patient safety is jeopardized (95%). A sample of the survey is attached. In order to measure knowledge gained, a pre and post activity quiz was devised to assess student understanding of ‘just culture’ and root cause analysis. A sample of the quiz is attached.
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