“I find the idea of a “just culture” compelling. It is not a simple agenda, because it involves balancing learning with blame, giving a sophisticated notion of accountability. It clearly places the onus for ensuring safety at an organisational / cultural level, within which the individual works, interacts and is accountable. But it does presuppose that the different people or groups broadly agree on the mission or values of healthcare. ‘Collateral Damage‘ forces one to question whether that assumption is correct. It is surely a call for reflection and learning: what should the mission of any healthcare provider be? How is that mission agreed on by both providers and consumers? How are values propagated across stakeholders? Etc. Assuming that patient safety is indeed valued, we all need to learn from cases such as this.”
Read the full post at Ann’s blog.
- Collateral Damage – the book
- National Center for Human Factors Engineering in Healthcare: Just Culture (the three behaviours)
- Just Culture Community – Just Culture (12-sided online booklet)
- Department of Health (UK) – An organisation with a memory