Just Culture: Balancing Safety and Accountability
Ashgate Publishing, Ltd., 2007 - 153 páginas
A just culture protects people's honest mistakes from being seen as culpable. But what is an honest mistake, or rather, when is a mistake no longer honest? Drawing on his experience with practitioners (in nursing, air traffic control and professional aviation) whose errors were turned into crimes, Dekker lays out a new view of just culture. This book will help you to create an environment where learning and accountability are fairly and constructively balanced.
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Why Bother with a Just Culture?
Between Culpable and Blameless
The Importance Risk and Protection of Reporting
The Importance Risk and Protection of Disclosure
Are All Mistakes Equal?
Hindsight and Determining Culpability
You Have Nothing to Fear if Youve Done Nothing Wrong
Without Prosecutors There Would be No Crime
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accident actions aftermath air traffic control aircraft airline approach autopilot aviation baby behavior Cairo international airport calls for accountability captain chapter co-pilot cockpit voice recorder consequences crew crime criminal culpable culture decision decision tree defensive disclose disclosure doctors domain expertise draw the line ethical Eurocontrol event example failure flight engineer happened healthcare hidden curriculum hindsight hindsight bias honest human error Ibid incident involved Israeli Israeli Air Force judge of instruction judgment judicial proceedings judiciary justice legal system lidocaine look Mara Medical error mg/ml mistake negligence normal normative errors nurse operator organization organization's organizational learning outcome patient pediatrics person pilot practitioners prescription problem procedures professional prosecution prosecutor protection question regulator responsibility risk runway safety data safety investigation seen solution stakeholders story Supreme Court Swedish Supreme Court technical error tell things trial trust truth turn vials victims violations wrong Xylocard