Just Culture: Balancing Safety and Accountability PDF
Preview Just Culture: Balancing Safety and Accountability
JUST CULTURE To: F.C.K., C.L., H.N., E.H. and P.N. Just Culture Balancing Safety and Accountability 2nd Edition SIDNEY DEKKER Griffith University, Australia CRC Press Taylor & Francis Group 6000 Broken Sound Parkway NW, Suite 300 Boca Raton, FL 33487-2742 © 2012 by Sidney Dekker CRC Press is an imprint of Taylor & Francis Group, an Informa business No claim to original U.S. Government works Printed on acid-free paper Version Date: 20160506 International Standard Book Number-13: 978-1-4094-4061-1 (Hardback) This book contains information obtained from authentic and highly regarded sources. Reasonable efforts have been made to publish reliable data and information, but the author and publisher can- not assume responsibility for the validity of all materials or the consequences of their use. The authors and publishers have attempted to trace the copyright holders of all material reproduced in this publication and apologize to copyright holders if permission to publish in this form has not been obtained. If any copyright material has not been acknowledged please write and let us know so we may rectify in any future reprint. Except as permitted under U.S. Copyright Law, no part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying, microfilming, and recording, or in any information storage or retrieval system, without written permission from the publishers. For permission to photocopy or use material electronically from this work, please access www.copy- right.com (http://www.copyright.com/) or contact the Copyright Clearance Center, Inc. (CCC), 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400. CCC is a not-for-profit organization that provides licenses and registration for a variety of users. For organizations that have been granted a photocopy license by the CCC, a separate system of payment has been arranged. Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. Visit the Taylor & Francis Web site at http://www.taylorandfrancis.com and the CRC Press Web site at http://www.crcpress.com Contents List of Figures and Tables vii Preface ix Prologue: A Nurse’s Error Became a Crime xv 1 What is the Right Thing to Do? 1 2 “You Have Nothing to Fear if You’ve Done Nothing Wrong” 15 3 Between Culpable and Blameless 25 4 Are All Mistakes Equal? 35 5 Report, Disclose, Protect, Learn 51 6 A Just Culture in Your Organization 73 7 The Criminalization of Human Error 87 8 Is Criminalization Bad For Safety? 103 9 Without Prosecutors, There Would Be No Crime 115 10 Three Questions For Your Just Culture 131 11 Why Do We Blame? 149 Epilogue 159 Index 165 9 Taylor & Francis ~ Taylor & Francis Group http://taylora ndfra ncis.com List of Figures and Tables Figure 10.1 A staggered approach to building a just culture 141 Table 5.1 The difference between disclosure and reporting for individuals and organizations 64 9 Taylor & Francis ~ Taylor & Francis Group http://taylora ndfra ncis.com Preface Keith Ramstead was a British cardiothoracic surgeon who moved to New Zealand. There, three patients died during or immediately after his operations, and he was charged with manslaughter.1 Not long before, a professional college had pointed to serious deficiencies in the surgeon’s work and found that seven of his cases had been managed incompetently. The report found its way to the police, who subsequently investigated the cases. This in turn led to the criminal prosecution against Ramstead. From Acts of God to Culpable Mismanagement of Risk We have not always looked at three dead patients as evidence of a possible crime, or as any form of reprehensible behavior. Turning to human error as explanation for an accident, and making it into a culpable act or a crime, is only a very recent way of dealing with failure. In fact, the whole idea of an “accident” is relatively modern.2 Up until the scientific revolution in the seventeenth century, we apparently had no need for a concept like “accident.” Religion and superstition supplied ample explanatory models for things that went wrong. We called it fate, predestination, God’s will, witchcraft, taboo- breaking. Where misfortune was going to hit was—as far as mortal humans were concerned—random, uncontrollable. It stayed this way for the next couple of hundred years, though ever fewer people bought into the idea that accidents had divine or demonic incitement behind them. In the early twentieth century, we began to see accidents as unfortunate but otherwise meaningless coincidences of space and time. As random physical events, though, we still did not consider accidents worthy of study. And we judged attempts to predict and prevent accidents as largely useless. Over the last thirty years, however, this interpretation of accidents has shifted dramatically. Startling failures such as the Three Mile Island nuclear accident in 1973 and the collision of two jumbo jets at Tenerife in 1977 moved accidents back onto the center stage of our societies. No longer do we see accidents as meaningless, uncontrollable events. On the contrary: Accidents are evidence that a particular risk was not managed well enough. And behind that mismanagement, there was a person, or multiple people. Today, even though we use the word quite freely, we have actually
The list of books you might like
