Just Culture

Just Culture

Author: Professor Sidney Dekker

Publisher: Ashgate Publishing, Ltd.

Published: 2012-10-01

Total Pages: 201

ISBN-13: 1409487024

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Building on the success of the 2007 original, Dekker revises, enhances and expands his view of just culture for this second edition, additionally tackling the key issue of how justice is created inside organizations. The goal remains the same: to create an environment where learning and accountability are fairly and constructively balanced. The First Edition of Sidney Dekker’s Just Culture brought accident accountability and criminalization to a broader audience. It made people question, perhaps for the first time, the nature of personal culpability when organizational accidents occur. Having raised this awareness the author then discovered that while many organizations saw the fairness and value of creating a just culture they really struggled when it came to developing it: What should they do? How should they and their managers respond to incidents, errors, failures that happen on their watch? In this Second Edition, Dekker expands his view of just culture, additionally tackling the key issue of how justice is created inside organizations. The new book is structured quite differently. Chapter One asks, ‘what is the right thing to do?’ - the basic moral question underpinning the issue. Ensuing chapters demonstrate how determining the ‘right thing’ really depends on one’s viewpoint, and that there is not one ‘true story’ but several. This naturally leads into the key issue of how justice is established inside organizations and the practical efforts needed to sustain it. The following chapters place just culture and criminalization in a societal context. Finally, the author reflects upon why we tend to blame individual people for systemic failures when in fact we bear collective responsibility. The changes to the text allow the author to explain the core elements of a just culture which he delineated so successfully in the First Edition and to explain how his original ideas have evolved. Dekker also introduces new material on ethics and on caring for the’ second victim’ (the professional at the centre of the incident). Consequently, we have a natural evolution of the author’s ideas. Those familiar with the earlier book and those for whom a just culture is still an aspiration will find much wisdom and practical advice here.


Creating a Just Culture

Creating a Just Culture

Author: Vivian B. Miller

Publisher: HC Pro, Inc.

Published: 2011

Total Pages: 191

ISBN-13: 1601467656

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Step-by-step guidance to create and sustain a just culture at your facility Earn 3 continuing education credits This practical resource explains the process of creating and sustaining a just culture in which staff members are encouraged to report adverse events to improve quality care. You'll get sure-fire strategies to gain buy-in from leadership, improve employee satisfaction, and turn mistakes and near-misses into useful data to improve processes and reporting. Help your nurses understand it's not the "who" but the "what" that went wrong. This book will help you: o Overcome potential roadblocks to culture change with successful strategies from accomplished patient safety, risk, and nursing experts o Motivate staff to report adverse events o Discover how a just culture increases patient safety, nurse satisfaction, and retention o Evolve your current culture into a just culture using the easy-to-understand, step-by-step instructions


Keeping Patients Safe

Keeping Patients Safe

Author: Institute of Medicine

Publisher: National Academies Press

Published: 2004-03-27

Total Pages: 485

ISBN-13: 0309187362

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Building on the revolutionary Institute of Medicine reports To Err is Human and Crossing the Quality Chasm, Keeping Patients Safe lays out guidelines for improving patient safety by changing nurses' working conditions and demands. Licensed nurses and unlicensed nursing assistants are critical participants in our national effort to protect patients from health care errors. The nature of the activities nurses typically perform â€" monitoring patients, educating home caretakers, performing treatments, and rescuing patients who are in crisis â€" provides an indispensable resource in detecting and remedying error-producing defects in the U.S. health care system. During the past two decades, substantial changes have been made in the organization and delivery of health care â€" and consequently in the job description and work environment of nurses. As patients are increasingly cared for as outpatients, nurses in hospitals and nursing homes deal with greater severity of illness. Problems in management practices, employee deployment, work and workspace design, and the basic safety culture of health care organizations place patients at further risk. This newest edition in the groundbreaking Institute of Medicine Quality Chasm series discusses the key aspects of the work environment for nurses and reviews the potential improvements in working conditions that are likely to have an impact on patient safety.


Making Healthcare Safe

Making Healthcare Safe

Author: Lucian L. Leape

Publisher: Springer Nature

Published: 2021-05-28

Total Pages: 450

ISBN-13: 3030711234

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This unique and engaging open access title provides a compelling and ground-breaking account of the patient safety movement in the United States, told from the perspective of one of its most prominent leaders, and arguably the movement’s founder, Lucian L. Leape, MD. Covering the growth of the field from the late 1980s to 2015, Dr. Leape details the developments, actors, organizations, research, and policy-making activities that marked the evolution and major advances of patient safety in this time span. In addition, and perhaps most importantly, this book not only comprehensively details how and why human and systems errors too often occur in the process of providing health care, it also promotes an in-depth understanding of the principles and practices of patient safety, including how they were influenced by today’s modern safety sciences and systems theory and design. Indeed, the book emphasizes how the growing awareness of systems-design thinking and the self-education and commitment to improving patient safety, by not only Dr. Leape but a wide range of other clinicians and health executives from both the private and public sectors, all converged to drive forward the patient safety movement in the US. Making Healthcare Safe is divided into four parts: I. In the Beginning describes the research and theory that defined patient safety and the early initiatives to enhance it. II. Institutional Responses tells the stories of the efforts of the major organizations that began to apply the new concepts and make patient safety a reality. Most of these stories have not been previously told, so this account becomes their histories as well. III. Getting to Work provides in-depth analyses of four key issues that cut across disciplinary lines impacting patient safety which required special attention. IV. Creating a Culture of Safety looks to the future, marshalling the best thinking about what it will take to achieve the safe care we all deserve. Captivatingly written with an “insider’s” tone and a major contribution to the clinical literature, this title will be of immense value to health care professionals, to students in a range of academic disciplines, to medical trainees, to health administrators, to policymakers and even to lay readers with an interest in patient safety and in the critical quest to create safe care.


Just Culture

Just Culture

Author: Sidney Dekker

Publisher: Ashgate Publishing, Ltd.

Published: 2012

Total Pages: 201

ISBN-13: 1409440605

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While many organizations see the value of creating a just culture they struggle when it comes to developing it. In this Second Edition, Dekker expands his views, additionally tackling the key issue of how justice is created inside organizations. Dekker also introduces new material on ethics and on caring for the' second victim' (the professional at the centre of the incident). Consequently, we have a natural evolution of the author's ideas.


Restorative Just Culture in Practice

Restorative Just Culture in Practice

Author: Sidney Dekker

Publisher: CRC Press

Published: 2022-06-15

Total Pages: 190

ISBN-13: 1000596397

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A restorative just culture has become a core aspiration for many organizations in healthcare and elsewhere. Whereas ‘just culture’ is the topic of some residual conceptual debate (e.g. retributive policies organized around rules,violations and consequences are ‘sold’ as just culture), the evidence base on, and business case for, restorative practice has been growing and is generating increasing, global interest. In the wake of an incident, restorative practices ask who are impacted, what their needs are and whose obligation it is to meet those needs. Restorative practices aim to involve participants from the entire community in the resolution and repair of harms. This book offers organization leaders and stakeholders a practical guide to the experiences of implementing and evaluating restorative practices and creating a sustainable just, restorative culture. It contains the perspectives from leaders, theoreticians regulators, employees and patient representatives. To the best of our knowledge, there is no book on the market today that can function as a guide for the implementation and evaluation of a just and learning culture and restorative practices. This book is intended to fill this gap. This book will provide, among other topics, an overview of restorative just culture principles and practices; a balanced treatment of the various implementations and evaluations of just culture and restorative processes; a guide for leaders about what to stop, start, increase and decrease in their own organizations; and an attentive to philosophical and historical traditions and assumptions that underlie just culture and restorative approaches. The interest in ‘just culture’, not just in healthcare but also in other fields of safety-critical practice, has been steadily growing over the past decade. It is a trending area. In this, it has become clear that 20-year-old retributive models not only hinder the acceleration of performance and organizational improvement but have also in some cases become a blunt HR instrument, an expression of power over justice and a way to stifle honesty, reporting and learning. What is new in this, then, is the restorative angle on just culture, as it has been developed over the last few years and now is practised and applied to HR, suicide prevention, healthcareimprovement, regulatory innovations and other areas.


The Just Culture Principles in Aviation Law

The Just Culture Principles in Aviation Law

Author: Francesca Pellegrino

Publisher: Springer Nature

Published: 2019-09-09

Total Pages: 161

ISBN-13: 303023178X

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This book reviews and critically analyzes the current legal framework with regard to a more just culture for the aviation sector. This new culture is intended to protect front-line operators, in particular controllers and pilots, from legal action (except in the case of willful misconduct or gross negligence) by creating suitable laws, regulations and standards. In this regard, it is essential to have an environment in which all incidents are reported, moving away from fears of criminalization. The approach taken until now has been to seek out human errors and identify the individuals responsible. This punitive approach does not solve the problem because frequently the system itself is (also) at fault. Introducing the framework of a just culture could ensure balanced accountability for both individuals and complex organizations responsible for improving safety. Both aviation safety and justice administration would benefit from this carefully established equilibrium.


Patient Safety Handbook

Patient Safety Handbook

Author: Barbara J. Youngberg

Publisher: Jones & Bartlett Publishers

Published: 2013

Total Pages: 677

ISBN-13: 0763774049

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Examines the newest scientific advances in the science of safety.


Quantum Safety

Quantum Safety

Author: Paul Stretton

Publisher: CRC Press

Published: 2022-02-22

Total Pages: 181

ISBN-13: 100054382X

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This book is the most comprehensive review of health and safety in half a century. Most organisational approaches to health and safety are based on the methodology developed during the 1970s, and despite the workplace changing beyond recognition since that time, these approaches have remained untouched. Quantum Safety will develop a new understanding fit for the modern workplace. Quantum Safety is an approach that is part of the "new view" debate. There have been a number of other new approaches to health and safety in recent years, and while they all have merit and improve understanding to help create the optimal, safe working environment, they have failed to significantly create the change desired. These approaches are often flawed at the philosophical or conceptual level or propose a solution without a pathway to implement the principles in safety-critical environments. Quantum Safety: The New Approach to Risk Management for the Complex Workplace is founded on a wholesale critical analysis of the conceptual foundations of health and safety before translating the revised principles into a tangible methodology. Central to the development of Quantum Safety is the application of Complexity Science. The traditional approach to health and safety is considered to be Newtonian – it uses linear models and deterministic analysis. Quantum Safety, due to the full consideration of Complexity Science, introduces multidimensional models and develops analysis based on probabilities. Crucially, this does not render Newtonian methodologies as worthless – in the same manner that Newtonian physics was able to take mankind to the moon, but required the quantum understanding within computers to make it possible – Quantum Safety provides the mechanisms to complete organisations’ safety-based journeys. The new mechanisms are fully developed for the reader at both macro and micro levels. How an organisation measures safety and what it values are reset and re-examined. How we investigate adverse events and the consequential actions taken with employees to develop a true Just Culture within a high-performing culture are also completely revised. Essentially, Quantum Safety creates a pathway for understanding health and safety in the complex modern world. To achieve that, new models are introduced to replace the dated, simple tools and a new language is developed to communicate this powerful approach. It will help propel an organisation from considering safety within a concept of industrialised failure avoidance to valuing safety as an integrated aspect of high performance.


The DevOps Handbook

The DevOps Handbook

Author: Gene Kim

Publisher: IT Revolution

Published: 2021-11-30

Total Pages: 477

ISBN-13: 1950508439

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This award-winning and bestselling business handbook for digital transformation is now fully updated and expanded with the latest research and new case studies! “[The DevOps Handbook] remains a must-read for any organization seeking to scale up its IT capability and expand DevOps practices across multiple departments or lines of business.” —Mike Perrow, TechBeacon For years, The DevOps Handbook has been the definitive guide for taking the successes laid out in the bestselling The Phoenix Project and applying them in any organization. Now, with this fully updated and expanded edition, it's time to take DevOps out of the IT department and apply it across the full business. Technology is now at the core of every company, no matter the business model or product. The theories and practices laid out in The DevOps Handbook are tools to be used by anyone from across the organization to create joy and succeed in the marketplace. The second edition features 15 new case studies, including stories from Adidas, American Airlines, Fannie Mae, Target, and the US Air Force. In addition, renowned researcher and coauthor of Accelerate, Dr. Nicole Forsgren, provides her insights through new and updated material and research. With over 100 pages of new content throughout the book, this expanded edition is a must read for anyone who works with technology. “[The DevOps Handbook is] a practical roadmap to improving IT in any organization. It's also the most valuable book on software development I've read in the past 10 years.” —Adam Hawkins, software developer and host of the podcast SmallBatches