Patient Safety and the "Just Culture"

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An Introduction to Just Culture“As far as I am concerned, when I say “careless” I am not talkingabout any kind of “reckless” operation of an aircraft, but simplythe most basic form of simple human error or omission that theBoard has used in these cases in its definition of“carelessness.” In other words, a simple absence of the duecare required under the circumstances, that is, a simple act ofomission, or simply“ordinary negligence,” a human mistake.”National Transportation Safety BoardAdministrative Law JudgeEngen v. Chambers and LangfordCopyright 2007, Outcome Engineering, LLC. All rights reserved.
The Problem StatementWhat system ofaccountability bestsupports systemsafety?SupportofSystemSafetyAs applied to:• Providers• Managers• Healthcare Institutions• RegulatorsBlame-FreeCulturePunitiveCultureCopyright 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: An Introduction to Just Culture“
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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