An important component in the creation of safer systems is the active engagement of all employees in reporting errors and hazards. Approaches that focus on punishing individuals instead of changing systems provide strong incentives for people to report only those errors they cannot hide. A punitive approach shuts off the information that is needed to identify faulty systems and create safer ones. In a punitive system, no one learns from their mistakes.
A just culture is an alternative to an overly punitive system and addresses the weaknesses of a solely blame-free approach. It acknowledges that competent professionals make mistakes, no system can be designed to produce perfect results, and even competent professionals will develop unhealthy norms such as shortcuts and routine rule violations. A just culture, however, has zero tolerance for reckless behaviour.
Principles of a Just Culture
Just Culture Algorithm
Algorithm To Guide Decision Making
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