An interesting and recent discussion paper from Sidney Dekker, exploring forgiveness as a ‘morally serious response’ to incidents, as opposed to retributive approaches. Tl;dr: · “while retribution addresses certain ethical concerns, it is incomplete and can be counterproductive, particularly for patient safety and organizational learning” · “Systems that focus primarily on individual blame risk fostering… Continue reading Forgiveness as morally serious response to errors in healthcare: A narrative review
Tag: restorative-culture
Allocation of Blame After a Safety Incident
This single page conference paper discussed an experiment on how blame is allocated following incidents. The scenario was a “realistic, but fictitious” incident involving a worker (both experienced or not experienced, depending on the scenario), whom is killed when touching an energised bus bar while feeding electrical wire into a pedestal. They systematically manipulated the… Continue reading Allocation of Blame After a Safety Incident
Compendium: Blame, Just Culture & language
Here’s another compendium of articles exploring blame and language in the construction of post-hoc causality explanations, or how blame effects learning and investigations. The other part covers some articles around Just Culture and restorative culture. Note: I’ve mostly focused on articles that I’ve either already summarised or that I could find a full text link… Continue reading Compendium: Blame, Just Culture & language
From individual behaviour to system weaknesses: The re-design of the Just Culture process in an international energy company. A case study
This 2018 paper explored the effects of a re-designed Just Culture (JC) process in an international energy company. It’s a solid read and worth your time – I’ve had to skip heaps. Providing background: · This organisation started using the James Reason JC framework in 201, but collective experience in the organisation “indicated that the… Continue reading From individual behaviour to system weaknesses: The re-design of the Just Culture process in an international energy company. A case study
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