Patient Safety and the "Just Culture"

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Copyright 2007, Outcome Engineering, LLC. All rights reserved.The Safety Task
Managing System ReliabilityDesign forSystem Reliability…100%SystemFailureSystem ReliabilitySuccessfulOperation• Human factors design toreduce the rate of error• Barriers to prevent failure• Recovery to capturefailures before theybecome critical• Redundancy to limit theeffects of failure0%PoorGoodFactors Affecting System Performance… knowing that systems will never be perfectCopyright 2007, Outcome Engineering, LLC. All rights reserved.
Page 1 and 2: Patient Safetyand the“Just Cultur
Page 3 and 4: Copyright 2007, Outcome Engineering
Page 5 and 6: An Introduction to Just Culture“T
Page 7 and 8: An Introduction to Just Culture“
Page 9: The Problem StatementWhat system of
Page 15 and 16: The Behaviors We Can Expect• Huma
Page 17 and 18: Accountability for Our BehaviorsHum
Page 19 and 20: It’s About a Proactive Learning C
Page 21 and 22: It’s About Changing Managerial Ex
Page 25 and 26: An Algorithm to Follow• One metho
Page 27: Thank YouDavid Marx, JDdmarx@outcom

Patient Safety and the "Just Culture"

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