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Perspectives on Safety > Interview
Just Culture, October 2007
An engineer and an attorney by training, David Marx, JD, is president of Outcome Engineering, a risk management firm. After a career focused on safety assessment and improvement in aviation, he has spent the last decade focusing on the interface between systems engineering, human factors, and the law. In 2001, he wrote a seminal paper describing the concept of just culture, which became a focal point for efforts to reconcile notions of "no blame" and "accountability." He has gone on to form the "Just Culture Community" to address these issues at health care institutions around the country.
Marx D. New York, NY: Columbia University; 2001.
Accountability is a concept that many wrestle with as they steer their organizations and patients toward understanding and accepting the idea of a blameless culture within the context of medical injury. Marx presents the concept from the legal perspective but does so for the non-barrister. Written prior to the acceptance of open disclosure or general policy support of it, the primer thoughtfully outlines the complex nature of deciding how best to hold individuals accountable for mistakes. Four key behavior concepts serve as the structure for the paper: human error, negligence, reckless conduct, and knowing violations. How they are applied to various situations in health care and how the individuals involved should be disciplined provide thoughtful reading.
Journal Article > Commentary
Larsen D, Cole R, Higton P. Nurs Stand. 2007;21:35-40.
By introducing several scenarios that illustrate the effective use of a decision-making tree, the authors emphasize the importance of fair response to medication error at both the individual and system levels.
Journal Article > Study
Rosenstein AH, O'Daniel M. Jt Comm J Qual Patient Saf. 2008;34:464-471.
This survey of clinicians and managers from more than 100 hospitals revealed that unprofessional behavior is common among both physicians and nurses. Respondents strongly agreed that disruptive behavior adversely affects patient safety and the quality of care, and the authors recommend various approaches that hospitals can implement to address communication and behavioral problems. A prior commentary discussed system-level solutions to addressing unprofessional behavior, and guidelines have been formulated to identify and address such issues. The concept of just culture has been proposed in order to maintain individual accountability for unsafe behaviors, while acknowledging that most errors occur as a result of system flaws.
Legislation/Regulation > Sentinel Event Alerts
Sentinel Event Alert. August 27, 2009;(43):1-3.
Despite the past decade's focus on improving patient safety, most health care organizations are still striving to achieve high reliability status—consistently providing high quality care while minimizing adverse events. In this sentinel event alert, the Joint Commission calls for senior health care leaders to establish a culture of safety within their organizations, use just culture principles to establish transparent and fair policies for addressing errors at the sharp end, and maintain robust structures for analyzing and responding to adverse events. Specific suggested actions include involving hospital boards and patients in safety efforts and making safety performance an explicit part of the evaluation for leaders. Adherence to sentinel event alert recommendations is assessed as part of Joint Commission accreditation surveys.
Journal Article > Commentary
Wachter RM, Pronovost PJ. N Engl J Med. 2009;361:1401-1406.
An early focus of the patient safety movement was a shift from the traditional culture of individual blame to one that investigated errors as the failure of systems, popularized by adoption of James Reason's Swiss cheese model of organizational accidents. In recent years, there has been some backlash against a unidimensional systems-focused model, with past commentaries exploring the tension between a "no blame" culture and individual accountability. Articles in this genre have considered this tension in the educational setting, and a popular construct involves a just culture framework, which differentiates "no blame" from blameworthy acts. This commentary, written by two of the leaders in the safety field, further explores the relationship between blame and accountability, discusses why enforcement of safety standards tends to be lax (particularly in cases involving physicians), and proposes a working balance that not only promotes a safety culture but also safe patient care. The authors highlight hand hygiene non-compliance as an example of a behavior that should be managed through an accountability framework, with providers held accountable for failure to adhere to a known safety standard. They also offer suggested penalties (mostly involving suspension of clinical privileges) for repeated failures to comply with hand hygiene and other established safe practices.