Patient Safety and the "Just Culture"

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An Introduction to Just Culture“People make errors, which lead to accidents.Accidents lead to deaths. The standard solutionis to blame the people involved. If we find outwho made the errors and punish them, we solvethe problem, right? Wrong. The problem isseldom the fault of an individual; it is the fault ofthe system. Change the people without changingthe system and the problems will continue.”Don NormanAuthor, the Design of Everyday ThingsCopyright 2007, Outcome Engineering, LLC. All rights reserved.
An Introduction to Just Culture“…No person may operate an aircraftin a careless or reckless mannerso as to endangerthe life or property of another.”Federal Aviation Regulations§ 91.13 Careless or Reckless OperationCopyright 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: An Introduction to Just Culture“T
Page 9 and 10: The Problem StatementWhat system of
Page 11 and 12: 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 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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