2017 AHC/NCAL Annual Convention & Expo

Patient Safety and the Just Culture

Tuesday, October 17
10:00 AM - 11:00 AM
Location: Breakers G-I
CE: Nurses: 1.0 | NAB: 1.0

How we think about work place accountability is inherently important. The concept of justice is the foundation of our society and is something that every American expects, including in the workplace.

Safety in the workplace is important. But how do we establish a culture that encourages open reporting of adverse events and risky situations and hold people and organizations accountable in a just manner? The challenge lies in distinguishing between a system that might create risks, a human error which may result in a bad outcome, and reckless behavior that intentionally puts lives or organizations at risk. Just Culture has been redefining our system of work place justice in many industries over the last 20 years, including health care.

Just Culture reshapes our understanding of accountability, the role of the system, and the role of human behavior, allowing us to distinguish between human behaviors to help us arrive at a consistent way to establish a safe environment by managing the system and behavior.

Learning Objectives:

David Marx

David Marx is CEO of Outcome Engenuity, a Minnesota-based risk management firm. David has a BS in Mechanical Systems Engineering (1985) and Juris Doctor in Law (1997). David’s firm currently spends the majority of its effort on helping high-consequence organizations develop values-supportive practices and culture.

David began his career as a Boeing aircraft design engineer. In his final years at Boeing, David organized a human factors and safety group. In his work at Boeing, David won the International Federation of Airworthiness’s Whittle Safety Award for his development of a human error investigation process used by airlines around the world.

In 1997, David launched a research and consulting practice focused on the management of human error through the integration of systems engineering, human factors, and the law. David has served as an advisor to the Federal Aviation Administration’s Human Factors Research Program and to the NASA Space Shuttle Program. David was the principal consultant to NASA in development of their major mishap investigation process, and he led an outside team to benchmark space shuttle processing quality. David has developed risk modeling methods, including an approach called socio- technical probabilistic risk assessment (ST-PRA), which has been used to model risk in aviation, space, rail, and healthcare.

In the healthcare sector, David has been working to help healthcare institutions and regulatory agencies reduce the risk of iatrogenic patient harm. In the area of system design, David’s ST-PRA process has been used to model and mitigate risks from wrong site surgery to medication errors. In the area of safety culture, David authored the document, “Patient Safety and the ‘Just Culture’: A Primer for Healthcare Executives,” for the National Institutes of Health. Widely seen as the father of “Just Culture,” David and his firm administer the Just Culture Community, a resource for organizations across industries who strive to create accountable, safety supportive cultures.

David’s second book, Dave’s Subs: A Novel Story About Workplace Accountability, was released in November 2015. David’s first book, Whack-a-Mole: The Price We Pay For Expecting Perfection, was released in September 2009.


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