Patient Safety and the "Just Culture"

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Managing Human ReliabilityDesign forHuman Reliability…100%HumanErrorHuman Reliability• Information• Equipment/Tools• Design/Configuration• Job/Task• Qualifications/Skills• Perception of Risk• Individual Factors• Environment/Facilities• Organizational Environment• Supervision• Communication0%PoorSuccessfulOperationFactors Affecting Human PerformanceGood… knowing humans will never be perfectCopyright 2007, Outcome Engineering, LLC. All rights reserved.
Copyright 2007, Outcome Engineering, LLC. All rights reserved.The <strong>Just</strong> Culture Model
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 and 10: The Problem StatementWhat system of
Page 11: Managing System ReliabilityDesign f
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 23 and 24: Copyright 2007, Outcome Engineering
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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