Patient Safety and the "Just Culture"

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An Introduction to Just CultureThe single greatest impediment toerror prevention in the medical industry is“that we punish people formaking mistakes.”Dr. Lucian LeapeProfessor, Harvard School of Public HealthTestimony before Congress onHealth Care Quality ImprovementCopyright 2007, Outcome Engineering, LLC. All rights reserved.
An Introduction to Just Culture“There are activities in which the degree ofprofessional skill which must be required is sohigh, and the potential consequences of thesmallest departure from that high standard areso serious, that one failure to perform inaccordance with those standards is enough tojustify dismissal.”Lord DenningEnglish JudgeCopyright 2007, Outcome Engineering, LLC. All rights reserved.
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Page 7 and 8: An Introduction to Just Culture“
Page 9 and 10: The Problem StatementWhat system of
Page 11 and 12: Managing System ReliabilityDesign f
Page 13 and 14: Copyright 2007, Outcome Engineering
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

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