Making Just Culture a Reality: One Organization's Approach
Page AH. AHRQ WebM&M [serial online]. October 2007.
We've all been there...something goes wrong, a patient is harmed, and we, as medical directors, managers, and administrators, are forced to judge the behavioral choices of another human being. Most of the time, we conduct this complex leadership function guided by little more than vague policies, personal beliefs, and intuition. Frequently, we are frustrated by the fact that many other providers have made the same mistake or behavioral choice, with no adverse outcome to the patient, and the behavior was overlooked. Quite understandably, the staff is frustrated by what appears to be inconsistent, irrational decision-making by leadership. The "just culture" concept teaches us to shift our attention from retrospective judgment of others, focused on the severity of the outcome, to real-time evaluation of behavioral choices in a rational and organized manner.
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In Conversation with...Steven J. Spear, DBA, MS, MS
AHRQ WebM&M [serial online]. August 2009.
Staggered Sensitivity Results
Guglielmo BJ. AHRQ WebM&M [serial online]. March 2007.
In Conversation with...David Marx, JD
AHRQ WebM&M [serial online]. October 2007.
External Inquiry into the adverse incident that occurred at Queen's Medical Centre, Nottingham, 4th January 2001.
Toft B. London, England: Department of Health; 2001.
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