NSG 321 Unit 6 just culture event review example

A Heparin Rate Error at 2 a.m.: A Just Culture Review of One Slip and One Workaround

Student Name

Department of Nursing, Herzing University

NSG 321: Advanced Leadership and Management

Instructor Name

February 26, 2026

A Heparin Rate Error at 2 a.m.: A Just Culture Review of One Slip and One Workaround

The Event

On a composite 28-bed cardiac step-down unit, a patient on a weight-based heparin infusion for a pulmonary embolism had an activated partial thromboplastin time (aPTT) drawn at 1 a.m. that was below the therapeutic range. The nomogram called for the rate to increase from 1,000 to 1,100 units per hour. The heparin concentration was 100 units per mL, so the correct pump rate was 11 mL per hour. At 2 a.m., the patient's nurse, Rachel, a registered nurse with four years on the unit, programmed the pump at 18 mL per hour, which delivered 1,800 units per hour. No second nurse checked the change. The 6 a.m. aPTT was well above range; the day nurse held the infusion according to the nomogram, recognized the rate, and reported the event. Over four hours, the patient received about 2,800 units more than ordered. There was no bleeding, and the patient required additional monitoring but suffered no lasting harm.

Reconstruction: What Was Known at the Time

I interviewed Rachel, the charge nurse, and two other night nurses, and reviewed the pump log, the medication record, and the staffing sheet. The aim was to understand the event as it looked at 2 a.m., not as it looks now that the outcome is known. Hindsight makes the error look obvious; at the time it was one of many tasks in a busy hour.

At 1:45 a.m., Rachel had five patients, one of whom was being prepared for an urgent transfer to the intensive care unit. She was paged about the aPTT result while in that patient's room. She calculated the new rate correctly on paper, 11 mL per hour, and wrote it on the paper nomogram. She then went to the heparin patient's room. The pump log shows she programmed the infusion in the pump's basic mode, which accepts any rate in mL per hour, rather than through the drug library, which would have asked for the dose in units per hour and flagged 1,800 units per hour as above the usual range. In the room, the patient's call light for the bathroom was on, and she assisted the patient before programming. She says she does not remember entering 18 and believes she read 18 from the previous patient's pump setting written on her report sheet, where the next line listed a different patient's infusion at 18 mL per hour.

The unit policy requires an independent double check by a second registered nurse for every heparin rate change. The other night nurse on her side of the unit was in the transferring patient's room. Rachel did not wait or ask the charge nurse. She told me that on nights, heparin double checks are often done after the fact or not at all when staff are busy, and that she had never seen anyone questioned about it.

System Conditions Present

Four conditions contributed. First, workload: two nurses on Rachel's side of the unit had ten patients, one of them unstable. Second, the pump's basic mode: a review of the pump logs for the previous month showed that about 40% of heparin infusions on the unit were running in basic mode. Nurses explained why: the drug library entry for heparin requires the patient's weight, and when a patient's weight is not entered in the pump profile, a workaround through basic mode is faster. Third, the report sheet: the unit's handwritten report sheet lists infusion rates for all of a nurse's patients close together, which invites reading the wrong line. Fourth, the double check: the policy assumes a second nurse is available within minutes, which on nights is often not true, and the practice of skipping it had become normal without anyone noticing a problem, because until this event nothing had gone wrong.

Classification

Marx (2001) sorts behavior into three groups. The first is human error, meaning an unintended slip or lapse. The second is at-risk behavior, a choice that raises risk when the person does not see the risk or thinks it is warranted. The third is reckless behavior, in which the person knowingly ignores a large risk that nothing justifies. The classification is applied to the act, not to the person or the outcome.

Entering 18 instead of 11 was human error. Rachel intended to enter the correct rate, had calculated it correctly, and made a slip in execution under distraction. Errors of this kind arise from the conditions surrounding a person as much as from the person (Reason, 2000). Using basic mode and skipping the double check were at-risk behaviors. They were choices, but choices the unit had normalized: many nurses made the same ones, the drug library workaround was common knowledge, and no one had been coached about either. Rachel did not believe she was taking a significant risk. Nothing in the reconstruction suggests reckless behavior. A substitution test supports this: asked what they would likely have done in the same situation, the three other night nurses interviewed said they might have made the same choices.

The Response to the Individual

For the slip, the response is support. I met with Rachel, told her that the rate entry was an error anyone could make under those conditions, and made sure she knew the patient had no lasting harm. Nurses involved in errors often experience significant distress, and the conversation included an offer of the peer support program. For the at-risk behaviors, the response is coaching: a conversation about why the double check and the drug library exist, what they would have caught, and what to do when a second nurse is not available, which is to call the charge nurse rather than proceed alone. The coaching is recorded as coaching, not discipline, and no disciplinary action follows. Treating a normalized shortcut as misconduct would punish one nurse for a practice the unit tolerated and would make the next nurse less likely to report (Dekker, 2016).

The Response to the System

The system response is larger than the individual one, because the conditions that produced this event are still in place for every nurse on the unit. Actions agreed with pharmacy, nursing informatics, and the unit practice council: patient weight will be entered in the pump profile at the time a heparin infusion is started, as part of the order verification step, removing the reason for the basic mode workaround; heparin infusions running in basic mode will appear on a weekly pump report reviewed by the unit educator; the report sheet will be redesigned so that each patient's infusions are in a separate box; and the charge nurse will act as the default second checker on nights when the nearest nurse is unavailable. The double check policy itself will be reviewed, because a check that cannot be done as written invites the drift that occurred here.

Protecting Reporting

The day nurse who reported the event was thanked, and the event was shared with the unit, without names, as an example of a report that led to changes. Staff were told plainly that the review found a system problem and that the nurse involved was coached, not disciplined. Whether staff continue to report depends on what they see happen to the people who report and to the people involved, more than on any statement of policy.

References

Dekker, S. (2016). Just culture: Restoring trust and accountability in your organization (3rd ed.). CRC Press.

Marx, D. (2001). Patient safety and the "just culture": A primer for health care executives. Columbia University.

Reason, J. (2000). Human error: Models and management. BMJ, 320(7237), 768-770. https://doi.org/10.1136/bmj.320.7237.768