What is the right thing to do? -- "You have nothing to fear if you've done nothing wrong" -- Between culpable and blameless -- Are all mistakes equal? -- Report, disclose, protect, learn -- A just culture in your organization -- The criminalization of human error -- Is criminalization bad for safety? -- Without prosecutors, there would be no crime -- Three questions for your just culture -- Why do we blame?

Following other contributions about the MAX accidents to this journal, this paper explores the role of betrayal and moral injury in safety engineering related to the U.S. federal regulator’s role in approving the Boeing 737MAX—a plane involved in two crashes that together killed 346 people. It discusses the tension between humility and hubris when engineers are faced with complex systems that create ambiguity, uncertain judgements, and equivocal test results from unstructured situations. It considers the relationship between moral injury, principled outrage (...) and rebuke when the technology ends up involved in disasters. It examines the corporate backdrop against which calls for enhanced employee voice are typically made, and argues that when engineers need to rely on various protections and moral inducements to ‘speak up,’ then the ethical essence of engineering—skepticism, testing, checking, and questioning—has already failed. (shrink)

This paper shows how discontinuities in the process of drug delivery enable but also underdetermine the isolation of a culprit in adverse medication events. A case example illustrates how we are forced to abandon conceptualizations of blame that assume a dichotomy , and shift instead to a more nuanced version that estimates the degree to which an actor desired, generated, or could have foreseen the harmful outcome, and the extent to which constraints external to the actor altered the event. The (...) paper concludes that meaningful safety interventions in a system as diverse, socially embedded and complex as health care delivery cannot just build on “good science” to generate “root” causes. Rather, they need to somehow be sensitive to how and which narratives of success and failure are created, as these constrain which countermeasures are likely to be encouraged, funded, and accepted. (shrink)

We say that celebrated accidents shape public perception of safety and risk in health care. Take the so-called celebrated story of the three Colorado nurses who, by administering bezathine penicillin intravenously, caused the death of a neonate. The nurses were charged with criminal negligence, with one pleading guilty to a reduced charge and another fighting the charge and eventually being exonerated. “Celebrated” accidents seem to follow a predictable script and cast participants in recognizable roles. They present heroes, survivors, and victims. (...) And, of course, they put villains, or anti-heroes, center stage – the chief protagonists of a fatal plot. (shrink)

A just culture is a culture of trust, learning and accountability. It is particularly important when an incident has occurred; when something has gone wrong. How do you respond to the people involved? What do you do to minimize the negative impact, and maximize learning? This third edition of Sidney Dekker's extremely successful Just Culture offers new material on restorative justice and ideas about why your people may be breaking rules. Supported by extensive case material, you will learn about safety (...) reporting and honest disclosure, about retributive just culture and about the criminalization of human error. Some suspect a just culture means letting people off the hook. Yet they believe they need to remain able to hold people accountable for undesirable performance. In this new edition, Dekker asks you to look at 'accountability' in different ways. One is by asking which rule was broken, who did it, whether that behavior crossed some line, and what the appropriate consequences should be. In this retributive sense, an 'account' is something you get people to pay, or settle. But who will draw that line? And is the process fair? Another way to approach accountability after an incident is to ask who was hurt. To ask what their needs are. And to explore whose obligation it is to meet those needs. People involved in causing the incident may well want to participate in meeting those needs. In this restorative sense, an 'account' is something you get people to tell, and others to listen to. Learn to look at accountability in different ways and your impact on restoring trust, learning and a sense of humanity in your organization could be enormous. (shrink)