Patient Safety and the "Just Culture"
Patient Safety and the "Just Culture"
Patient Safety and the "Just Culture"
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An Introduction to <strong>Just</strong> Culture“People make errors, which lead to accidents.Accidents lead to deaths. The st<strong>and</strong>ard solutionis to blame <strong>the</strong> people involved. If we find outwho made <strong>the</strong> errors <strong>and</strong> punish <strong>the</strong>m, we solve<strong>the</strong> problem, right? Wrong. The problem isseldom <strong>the</strong> fault of an individual; it is <strong>the</strong> fault of<strong>the</strong> system. Change <strong>the</strong> people without changing<strong>the</strong> system <strong>and</strong> <strong>the</strong> problems will continue.”Don NormanAuthor, <strong>the</strong> Design of Everyday ThingsCopyright 2007, Outcome Engineering, LLC. All rights reserved.
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