A just culture after Mid Staffordshire

Dekker, Sidney W. A. and Hugh, Thomas B. (2014) A just culture after Mid Staffordshire. BMJ Quality and Safety, 23 5: 356-358. doi:10.1136/bmjqs-2013-002483

Author Dekker, Sidney W. A.
Hugh, Thomas B.
Title A just culture after Mid Staffordshire
Journal name BMJ Quality and Safety   Check publisher's open access policy
ISSN 2044-5415
Publication date 2014-05-01
Year available 2014
Sub-type Critical review of research, literature review, critical commentary
DOI 10.1136/bmjqs-2013-002483
Open Access Status Not yet assessed
Volume 23
Issue 5
Start page 356
End page 358
Total pages 3
Place of publication London, United Kingdom
Publisher BMJ Group
Language eng
Subject 2719 Health Policy
Abstract There has been much public and media outrage in the wake of the scandal about the standard of healthcare delivered at Stafford Hospital. Using published evidence in the safety literature, we examine the distinction between our need to understand what happened, the practical need for preventing recurrence, and the age-old philosophical need to explain suffering. Investigations of what happened can identify the many detailed explanatory factors behind a particular outcome—including the actions and assessments of individual caregivers. These, however, do not necessarily constitute the change variables for preventing recurrence, as those might lie elsewhere in the governance of a complex system. And neither says much about the nature and apparent randomness of suffering in the particular circumstances of individual patients, even if that might be a most pressing question people want answers to in the wake of such a scandal. To promote safety and quality, we encourage a sensitivity to the differences between understanding, satisfying demands for justice, and avoiding recurrence. This might help a just culture in the wake of Mid Staffordshire, as it avoids expectations of an inquiry—independent or public—to do triple duty.
Keyword Human Error
Human Factors
Patient Safety
Safety Culture
Q-Index Code CX
Q-Index Status Confirmed Code
Institutional Status UQ

Document type: Journal Article
Sub-type: Critical review of research, literature review, critical commentary
Collections: Non HERDC
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School of Psychology Publications
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