Marx JustculturePatient Safety and the “Just Culture”:
A Primer for Health Care Executives, Prepared by David Marx, JD, for Columbia University under a grant provided by the National Heart, Lung, and Blood Institute

A lot.

There’s an interesting discussion underway at e-paients.net, about a recent case in Minnesota, which I was asked to (and did) comment on.

(e-patient) Dave brought up an important point, which concerns holding people accountable. Is it for the error, or knowing that the potential for error exists, or both?

I remembered this excellent paper from my files about this, and fortunately it is public domain, since it has been funded by our tax dollars. It’s useful to review the principles contained in it, which include supporting accountability and learning at the same time. Interesting that a lot of smart people have already done the thinking. Now we need to operationalize it.

With regard to the discussion on e-patients, I also remembered something about me. Whenever I walk into one of my organization’s medical centers, I assume that I am 100 % accountable for everything that is happening there. As I walk by the pharmacy, the lab, and head up to primary care, I imagine that my role is to protect every patient receiving care in all of those areas, whether or not I am directly involved in providing that care.

Now, imagine that every physician, staff member, patient, patient’s family, community member, carried themselves that way in every hospital and medical center. What would health care be like?

This cannot happen unless we support the idea that everyone on the care team, patient included, deserves access to all of the information about their care.

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