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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.
Stabile M, Webster CS, Merry AF. APSF Newsletter. Fall 2007;22:44-47.
To reduce anesthesia administration errors, the authors propose changing the organizational culture to foster a better understanding of human error and to adopt lasting safety principles.
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.