| Course | NUR 659 Healthcare Safety, Just Culture, and Regulation |
|---|---|
| Module | Module 10 |
| Paper type | closing reflective journal on patient safety leadership |
| Length | About 460 words, 3 pages |
| Format | APA 7 student paper |
| School | Southern New Hampshire University |
| Program | MSN |
| Updated | September 2026 |
Free sample paper for NUR 659 Module 10
Module Ten Journal
I Used to Ask Who Made the Mistake
When a medication error happened on my unit, my first thought as charge nurse was always the same: who did it? I considered myself fair, and I never shouted at anyone, but the question shaped everything that followed. This course has replaced it with a different one.
Reason (2000) contrasted a person-centered view of error, which looks for carelessness or forgetfulness in whoever was at the bedside, and the system approach, which accepts that people will make mistakes and asks why the defenses failed. When a colleague gave insulin to the wrong patient this year, the old me would have focused on her. Instead, I found myself asking how many times that night the scanner had failed and why the record let her type in an identifier without a second check. The answers pointed to problems I could help fix, which is more than blaming her would ever have done.
The second shift was more personal. Tucker and Spear (2006) watched hospital nurses at work and found that they ran into broken equipment, missing supplies and unavailable information several times a shift, and that they almost always worked around the problem instead of reporting it. Reading that, I counted my own workarounds during one shift: borrowing a pump from another room, looking up an order on a colleague's login when mine timed out, skipping a scan when the scanner froze. I had been proud of my resourcefulness. I now see that every workaround I quietly perform hides a problem from the people who could fix it, and teaches newer nurses that shortcuts are how good nurses get things done.
The third shift was about my colleague. Wu (2000) gave the name second victim to the nurse or doctor behind a harmful mistake, who often suffer guilt and shame with little support. After the insulin event, I saw her cry in the supply room and I did not know what to say. Now I understand that saying nothing felt like judgment. Our new peer support program exists because people like her were left alone, and I have signed up to be trained.
I will hold myself to three things on my unit. I will ask what failed before I ask who was involved. I will report my own workarounds, starting with a weekly list of broken equipment that goes to the manager and biomedical engineering, and I will ask my team to do the same. And when a colleague is involved in an error, I will reach out within a day, before the investigation, simply to ask how they are. I used to ask who made the mistake. Now I want to know what let it happen, and who needs help afterward.
References
Reason, J. (2000). Human error: Models and management. BMJ, 320(7237), 768-770. https://doi.org/10.1136/bmj.320.7237.768
Tucker, A. L., & Spear, S. J. (2006). Operational failures and interruptions in hospital nursing. Health Services Research, 41(3, Pt. 1), 643-662. https://doi.org/10.1111/j.1475-6773.2006.00502.x
Wu, A. W. (2000). Medical error: The second victim. BMJ, 320(7237), 726-727. https://doi.org/10.1136/bmj.320.7237.726
What the NUR 659 Module 10 instructions ask for
At the end of NUR 659, the journal usually invites you to look honestly at how your understanding of safety, and your part in it, has changed. The writing is personal, but two or three scholarly sources in APA 7 are generally expected. Roughly 400 to 600 words fits most versions. Choose a few genuine shifts in thinking, ground each in a specific moment from your own work, such as an error on your unit or a habit you noticed in yourself, tie each shift to a reading and close with actions a unit manager or colleague could watch you take in the months ahead. Include at least one habit of your own that you want to change.
How this NUR 659 Module 10 journal example is built
This journal is written by a charge nurse moving into safety leadership. Reason's system approach replaces her habit of asking who made an error with asking which defenses failed after a colleague's insulin mistake. Tucker and Spear's research leads her to count her own workarounds in one shift and see how they hide problems. Wu's second victim concept changes how she would respond to a colleague crying in the supply room. It closes with three promises: ask what failed first, report her own workarounds weekly and reach out to colleagues within a day after an error. Its voice is candid about her own shortcuts. The last line answers the title.
Where the NUR 659 Module 10 rubric puts the points
Safety reflections in NUR 659 are generally assessed on the depth of change described, how clearly readings explain it, relevance to the writer's role, organization and APA 7 mechanics. Entries that stand out include an honest look at the writer's own behavior, such as workarounds, rather than only at others. Graders reward concrete moments, accurate use of safety concepts and commitments that are specific enough for a colleague to observe. Linking personal practice to system learning, for example reporting workarounds so they can be fixed, shows that the writer understands how individual habits and organizational safety connect. Honesty about one's own habits carries weight. Observable commitments matter most.
NUR 659 Module 10 help: the mistakes that cost points
Safety journals lose points when they describe concepts without applying them to the writer's own practice, when the writer examines only others' behavior, when readings are cited but not connected to events or when commitments are too general. Another gap is ignoring the emotional side of errors. Choose real shifts, ground them in moments, include your own habits, tie each to a source and end with observable actions. If your prompt asks about speaking up, teamwork training or safety in a specific setting, send it with your NUR 659 notes so the reflection addresses that theme. Name one habit of your own you will change. Make each promise observable.
Get NUR 659 Module 10 written to your instructions
Name the NUR 659 readings that changed how you see errors and share the prompt. We will write an honest first-person piece that roots each shift in a moment from your own work, cites the reading behind it and closes with promises for your unit, within 24 to 48 hours, free the first time. The paper above is an original model document written by our desk, not a submitted student paper and not an official Southern New Hampshire University document.
More NUR 659 papers and related MSN samples
- NUR 659 Module 1 Discussion: What the Harm Data Show Two Decades After To Err Is Human
- NUR 659 Module 2 Systems Paper: Why Good Nurses Make Errors
- NUR 659 Module 3 Milestone One: A Root Cause Analysis That Ends in Strong Actions
- NUR 659 Module 4 Just Culture Paper: Error, At-Risk Behavior or Recklessness
- NUR 659 Module 5 Milestone Two: Choosing Proven Interventions: A Bundle and a Checklist
- NUR 659 Module 6 Disclosure Paper: Telling Patients the Truth and Caring for the Clinician Who Erred
- NUR 659 Module 7 Milestone Three: Measuring Harm and Safety Culture
- NUR 659 Module 8 Regulation Paper: The Rules Around Patient Safety
- NUR 659 Module 9 Final Project: A Hospital Patient Safety Plan From Culture to Measurement
- NUR 531 Module 9 Project Three: A Policy Update for a Hospital Water Management Program
- NUR 540 Module 5 Short Paper: An Asthma Exacerbation in a School-Age Child
- NUR 633 Module 6 Telehealth Paper: Monitoring Heart Failure at Home
- NUR 560 Module 2 Focused Assessment: Chest Pain in a 58-Year-Old With a Ranked Differential
NUR 659 Module 10 questions, answered
Where can I find a free NUR 659 Module 10 Journal sample?
The whole entry is here: a charge nurse reflects on systems thinking, her own workarounds and the second victim, with three commitments for her unit.
What should a NUR 659 closing reflection include?
Genuine shifts in how you understand safety, specific moments from your practice, the readings behind them and observable commitments.
Why do workarounds matter for patient safety?
They keep care moving but hide system problems from people who could fix them and teach others that shortcuts are normal.
What is the system approach to error?
Reason's approach that accepts humans will err and asks why defenses failed rather than focusing only on who made the mistake.
How can colleagues support a second victim?
By reaching out promptly and simply asking how they are, and by connecting them with peer support.