Just culture: Balancing safety and accountability, 2nd edition

Just Culture: Balancing Safety and Accountability, 2nd Edition

Volumn , Issue , 2012, Pages 1-171

  Dekker, Sidney ^a  

^a GRIFFITH UNIVERSITY   (Australia)

Author keywords

[No Author keywords available]

Indexed keywords

EID: 84900237281     PISSN: None     EISSN: None     Source Type: Book    
DOI: None     Document Type: Book

References (145)

1. Skegg PDG. Criminal prosecutions of negligent health professionals: The New Zealand experience. Medical Law Review 1998;6:220-46.
2. Green J. The ultimate challenge for risk technologies: Controlling the accidental. In: Summerton J, Berner B, eds. Constructing Risk and Safety in Technological Practice. London: Routledge; 2003.
3. HogstaDomstolen. Verdict B 2328-05. In: Court HDSS, ed. Stockholm; 2006:1-6.
4. Ferguson J, Fakelmann R. The culture factor. Frontiers of Health Services Management 2005;22:33-40.
5. GAIN. Roadmap to a just culture: Enhancing the safety environment. Global Aviation Information Network (Group E: Flight Ops/ATC Ops Safety Information Sharing Working Group); 2004.
6. Reason JT. Managing The Risks of Organizational Accidents. Aldershot, UK: Ashgate Publishing Co.; 1997.
7. Alicke MD. Culpable control and the psychology of blame. Psychological Bulletin 2000;126:556-574.
8. HogstaDomstolen. Verdict B 2328-05. In: Court HDSS, ed. Stockholm; 2006:1-6.
9. Wilkinson S. The Oscar November incident. Air & Space 1994:80-7.
10. Visotzky BL. The Genesis of Ethics. 1st ed New York: Crown Publishers; 1996.
11. Rawls J. A Theory of Justice. Cambridge, MA: Harvard University Press; 2003.
12. Wilkinson S. The Oscar November incident. Air & Space 1994:80-7.
13. Berlinger N. After Harm: Medical Error and the Ethics of Forgiveness. Baltimore, MD: Johns Hopkins University Press; 2005.
14. Bosk C. Forgive and Remember: Managing Medical Failure. Chicago, IL: University of Chicago Press; 2003.
15. Brennan TA, Sox CA, Burstin HR. Relation between negligent adverse events and the outcomes of medical malpractice litigation. The New England Journal of Medicine 1996;335:1963-7.
16. Dauer EA. Ethical misfits: Mediation and medical malpractice litigation. In: Sharpe VA, ed. Accountability: Patient Safety and Policy Reform. Washington DC: Georgetown University Press; 2004:185-202.
17. Hidden A. Clapham Junction Accident Investigation Report. London: HMSO; 1989.
18. Lanir Z. The reasonable choice of disaster: The shooting down of the Libyan airliner on 21 February 1973. Journal of Strategic Studies 1989;12:479-93.
19. Dekker SWA, Laursen T. From punitive action to confidential reporting: A longitudinal study of organizational learning. Patient Safety & Quality Healthcare 2007;5:50-6.
20. Dekker SWA, Hugh TB. Balancing "no blame" with accountability in patient safety. New England Journal of Medicine 2010;362:275.
21. Dekker SWA, Laursen T. From punitive action to confidential reporting: A longitudinal study of organizational learning. Patient Safety & Quality Healthcare 2007;5:50-6.
22. Barach P, Small SD. Reporting and preventing medical mishaps: Lessons from nonmedical near miss reporting systems. British Medical Journal 2000;320:759-63.
23. Vaughan D. The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA. Chicago, IL: University of Chicago Press; 1996.
24. Billings CE. Aviation Automation: The Search for a Human-centered Approach. Mahwah, NJ: Lawrence Erlbaum Associates; 1997.
25. Sharpe VA. Promoting patient safety: An ethical basis for policy deliberation. Hastings Center Report 2003;33:S2-19.
26. Guardian. The Guardian 2007 18 March;Sect. 1.
27. Berlinger N. After Harm: Medical Error and the Ethics of Forgiveness. Baltimore, MD: Johns Hopkins University Press; 2005.
28. Cohen JR. Legislating apology: The pros and cons. University of Cincinnati Law Review 2002;70:819-72.
29. Berlinger N. After Harm: Medical Error and the Ethics of Forgiveness. Baltimore, MD: Johns Hopkins University Press; 2005.
30. Marx D. Patient Safety and the "Just Culture": A Primer for Health Care Executives. New York: Columbia University; 2001.
31. Dekker SWA. Doctors are more dangerous than gun owners: A rejoinder to error counting. Human Factors 2007;49:177-84.
32. Becker HS. Outsiders: Studies in the Sociology of Deviance. London: Free Press of Glencoe; 1963.
33. Skegg PDG. Criminal prosecutions of negligent health professionals: The New Zealand experience. Medical Law Review 1998;6:220-46.
34. Dekker SWA. Criminalization of medical error: Who draws the line? ANZ Journal of Surgery 2007;77:831-7.
35. Dekker SWA. Just Culture: Balancing Safety and Accountability. Aldershot, England: Ashgate Publishing Co.; 2007.
36. Merry AF, McCall Smith A. Errors, Medicine and the Law. Cambridge: Cambridge University Press; 2001.
37. Gephart RP. Making sense of organizationally based environmental disasters. Journal of Management 1984;10:205-25.
38. Anderson RE. Medical Malpractice: A Physician's Sourcebook. New York: Humana Press; 2005.
39. Berlinger N. After Harm: Medical Error and the Ethics of Forgiveness. Baltimore, MD: Johns Hopkins University Press; 2005.
40. Dekker SWA, Laursen T. From punitive action to confidential reporting: A longitudinal study of organizational learning. Patient Safety & Quality Healthcare 2007;5:50-6.
41. Wolf ZR. Medication Errors: The Nursing experience. Albany, NY: Delmar; 1994.
42. Serembus JF, Wolf ZR, Youngblood N. Consequences of fatal medication errors for healthcare providers: A secondary analysis study. MedSurg Nursing 2001;10:193-201.
43. Berlinger N. After Harm: Medical Error and the Ethics of Forgiveness. Baltimore, MD: Johns Hopkins University Press; 2005.
44. Meurier CE, Vincent CA, Parmar DG. Nurses' responses to severity dependent errors: A study of the causal attributions made by nurses following an error. Journal of Advanced Nursing 1998;27:349-54.
45. Snook SA. Friendly Fire: The Accidental Shootdown of US Black Hawks Over Northern Iraq. Princeton, NJ: Princeton University Press; 2000.
46. Christensen JF, Levinson W, Dunn PM. The heart of darkness: The impact of perceived mistakes on physicians. Journal of General Internal Medicine 1992;7:424-31.
47. Friel A, White T, Alistair H. Posttraumatic stress disorder and criminal responsibility. Journal of Forensic Psychiatry and Psychology 2008;19:64-85.
48. Friel A, White T, Alistair H. Extended suicide attempt: Psychopathology, personality and risk factors. Psychopathology 2000;33:5-10.
49. Tyler K. Helping employees cope with grief. HR Magazine 2003;48:54-8.
50. Sharpe VA. Accountability: Patient Safety and Policy Reform. Washington, DC: Georgetown University Press; 2004.
51. Anderson RE. Medical Malpractice: A Physician's Sourcebook. New York: Humana Press; 2005.
52. Serembus JF, Wolf ZR, Youngblood N. Consequences of fatal medication errors for healthcare providers: A secondary analysis study. MedSurg Nursing 2001;10:193-201.
53. Christensen JF, Levinson W, Dunn PM. The heart of darkness: The impact of perceived mistakes on physicians. Journal of General Internal Medicine 1992;7:424-31.
54. Dekker SWA, Laursen T. From punitive action to confidential reporting: A longitudinal study of organizational learning. Patient Safety & Quality Healthcare 2007;5:50-6.
55. Cooper CL, Payne R. Causes, Coping, and Consequences of Stress at Work. Chichester; New York: Wiley; 1988.
56. Leonhardt J, Vogt J. Critical Incident Stress Management in Aviation. Aldershot, UK: Ashgate Publishing Co.; 2006.
57. Cohen-Charash Y, Spector PE. The role of justice in organizations: A metaanalysis. Organizational Behavior and Human Decision Processes 2001;86:278-321.
58. Conquitt JA, Conlon DE, Wesson MJ, Porter COLH, Ng KY. Justice at the millennium: A meta-analytic review of 25 years of organizational justice research. Journal of Applied Psychology 2001;86:425-45.
59. GAIN. Roadmap to a just culture: Enhancing the safety environment. Global Aviation Information Network (Group E: Flight Ops/ATC Ops Safety Information Sharing Working Group); 2004.
60. Dekker SWA. The Field Guide to Understanding Human Error. Aldershot, UK: Ashgate Publishing Co; 2006.
61. Pellegrino ED. Prevention of medical error: Where professional and organizational ethics meet. In: Sharpe VA, ed. Accountability: Patient Safety and Policy Reform. Washington DC: Georgetown University Press; 2004:83-98.
62. Berlinger N. After Harm: Medical Error and the Ethics of Forgiveness. Baltimore, MD: Johns Hopkins University Press; 2005.
63. Dauer EA. Ethical misfits: Mediation and medical malpractice litigation. In: Sharpe VA, ed. Accountability: Patient Safety and Policy Reform. Washington DC: Georgetown University Press; 2004:185-202.
64. Lerner JS, Tetlock PE. Accounting for the effects of accountability. Psychological Bulletin 1999;125:255-75.
65. Dekker SWA, Laursen T. From punitive action to confidential reporting: A longitudinal study of organizational learning. Patient Safety & Quality Healthcare 2007;5:50-6.
66. Morreim EH. Medical errors: Pinning the blame versus blaming the system. In: Sharpe VA, ed. Accountability: Patient Safety and Policy Reform. Washington DC: Georgetown University Press; 2004:213-32.
67. Anon. Texas executives faulted in BP explosion. International Herald Tribune 2007 May 4;Sect. 10.
68. Ter Kulle A. Safety versus justice. Canso News 2004;18:1-2.
69. Thomas G. A crime against safety. Air Transport World 2007:57-9.
70. Pandit MS. Medical negligence: Criminal prosecution of medical professionals, importance of medical evidence: Some guidelines for medical practitioners. Indian Journal of Urology 2009;25:379-83.
71. Michaels D. When a tragedy becomes a crime: Prosecutors probe air disasters. The Wall Street Journal 2008 September 9;Sect. 17.
72. Michaels D. Flying in the Face of Criminalization. Farnham, UK: Ashgate Publishing Co.; 2010.
73. ICAO. Working paper of the 36th session of the Assembly: Protection of certain accident and incident records and of safety data collection and processing systems in order to improve aviation safety. In: Organization ICA, ed. Montréal: International Civil Aviation Organization; 2007.
74. FSF. Aviation safety groups issue joint resolution condemning criminalization of accident investigations. In: Foundation FS, ed. Washington, DC: Flight Safety Foundation; 2006.
75. Tunisair pilots sentenced over Siciliy crash. RTE, 2009. (Accessed 4 February, 2010, at http://www.rte.ie/news/2009/0325/italy.html.)
76. Ruitenberg B. Court case against Dutch controllers. The Controller 2002;41: 22-5.
77. Wilkinson S. The Oscar November incident. Air & Space 1994:80-7.
78. Brothers C, Maynard M. More than 150 die in Madrid plane crash. New York Times 2008.
79. Flight risk: The threat of criminalization. 2009. (Accessed 2010, at http://www.aviationnow.com/aw/jsp_includes/articlePrint.jsp?storyID=news/bca0309p1.xml&headLine=FlightRisk: The Threat of Criminalization.)
80. Learmount D, Modola P. ATC body blasts Linate verdicts. Flight International 2004 April 4.
81. Helios trial examines technical aspects. 2009. (Accessed 5 February, 2010, at http://www.cyprus-mail.com/helios/helios-trial-examines-technical-aspects.)
82. Michaels D. When a tragedy becomes a crime: Prosecutors probe air disasters. The Wall Street Journal 2008 September 9;Sect. 17.
83. Thomas G. Aviation on trial. Air Transport World 2002:31-3.
84. Akerberg M. Nationellt patientsäkerhetscentrum ska driva på kunskapsstyrning (National Patient Safety Center will drive growth of knowledge). Läkertidningen 2008.
85. Masters and pilots jailed for Neftegaz-67 casualty. Lloyds List, 2010. (Accessed 20 January, 2010, at http://www.lloydslist.com/art/1263565647614.)
86. ENR. Human error cited in bridge collapse. Engineering News-Record 1997:18.
87. Prakash SS. The inhuman error: Lessons from Bhopal. New Management 1985;3:40-5.
88. Tingvall C, Lie A. The concept of responsibility in road traffic (Ansvarsbegreppet i vägtrafiken). In: Transportforum. Linköping, Sweden; 2010.
89. Woods DD, Dekker SWA, Cook RI, Johannesen LJ, Sarter NB. Behind Human Error. Aldershot, UK: Ashgate Publishing Co.; 2010.
90. Hollnagel E, Amalberti R. The emperor's new clothes: Or whatever happened to 'human error'? In: Dekker SWA, ed. 4th international workshop on human error, safety and systems development; 2001; Linköping, Sweden: Linköping University; 2001. p. 1-18.
91. Phillips S, Grattet R. Judicial rhetoric, meaning-making, and the institutionalization of hate crime law. Law & Society Review 2000;34:567-606.
92. Jacobs JB, Henry JS. The social construction of a hate crime epidemic. The Journal of Criminal Law and Criminology 1996;86:366-91.
93. Merry AF, Peck DJ. Anaesthetists, errors in drug administration and the law. New Zealand Medical Journal 1995;108:185-7.
94. Mee CL. Should human error be a crime? Nursing 2007:6.
95. Moran D. I was treated like a criminal after a harmless drug error. Nursing Standard 2008:33.
96. Reissner D. A criminal mistake? Chemist & Druggist 2009;271:8-9.
97. Ödegård S, ed. I rättvisans namn (In the name of justice). Stockholm: Liber; 2007.
98. Anderson RE. Medical Malpractice: A Physician's Sourcebook. New York: Humana Press; 2005.
99. Berlin L. Malpractice issues in radiology: Hindsight bias. American Journal of Roentgenology 2000;175(3):597-601.
100. Arkes HR, Saville PD, Wortmann RL, Harkness AR. Hindsight bias among physicians weighing the likelihood of diagnoses. Journal of Applied Psychology 1981;66:252-5.
101. Hawkins SA, Hastie R. Hindsight: Biased judgments of past events after the outcomes are known. Psychological Bulletin 1990;107:311-27.
102. LaBine SJ, LaBine G. Determinations of negligence and the hindsight bias. Law and Human Behavior 1996;20:501-16.
103. Roese NJ, Olson JM. Counterfactuals, causal attributions, and the hindsight bias: A conceptual integration. Journal of Experimental Social Psychology 1996;32:197-227.
104. Hugh TB, Dekker SWA. Hindsight bias and outcome bias in the social construction of medical negligence: A review. Journal of Law and Medicine 2009;16:846-57.
105. Laudan L. Truth, Error, and Criminal Law: An Essay in Legal Epistemology. Cambridge; New York: Cambridge University Press; 2006.
106. Dripps DA. Fundamental retribution error: Criminal justice and the social psychology of blame. Vanderbilt Law Review 2003;56:1381-438.
107. Anderson JC, Jennings MM, Lowe DJ, Reckers PM. The mitigation of hindsight bias in judges' evaluation of auditor decisions. Auditing 1997;16:20-39.
108. Wagenaar WA. Vincent plast op de grond: Nachtmerries in het Nederlands recht (Vincent urinates on the ground: Nightmares in Dutch law). Amsterdam: Uitgeverij Bert Bakker; 2006.
109. Rowe M. The rest is silence. Health Affairs 2002;21:232-6.
110. Thomas G. Aviation on trial. Air Transport World 2002:31-3.
111. Berlinger N. After Harm: Medical Error and the Ethics of Forgiveness. Baltimore, MD: Johns Hopkins University Press; 2005.
112. Accident report: Crash of Pinnacle Airlines Flight 3701, Bombardier CL600-2-B19, N8396A, Jefferson City, Missouri, October 14, 2004. Washington, DC: National Transportation Safety Board; 2007. Report No.: NTSB/AAR-07/01.
113. Dekker SWA. The Field Guide to Understanding Human Error. Aldershot, UK: Ashgate Publishing Co.; 2006.
114. McKenna JT. Criminal, safety probes at odds. Aviation Week & Space Technology 1999;151:47-8.
115. North DM. Oil and water, cats and dogs. Aviation Week & Space Technology 2002;156:70.
116. Ruitenberg B. Court case against Dutch controllers. The Controller 2002;41:22-5.
117. Ter Kulle A. Safety versus justice. Canso News 2004;18:1-2.
118. Bittle S, Snider L. From manslaughter to preventable accident: Shaping corporate criminal liability. Law & Policy 2006;28.
119. Merry AF, McCall Smith A. Errors, Medicine and the Law. Cambridge: Cambridge University Press; 2001.
120. Wilkinson S. The Oscar November incident. Air & Space 1994:80-7.
121. Merry AF, Peck DJ. Anaesthetists, errors in drug administration and the law. New Zealand Medical Journal 1995;108:185-7.
122. Lerner JS, Tetlock PE. Accounting for the effects of accountability. Psychological Bulletin 1999;125:255-75.
123. North DM. Oil and water, cats and dogs. Aviation Week & Space Technology 2002;156:70.
124. McKenna JT. Criminal, safety probes at odds. Aviation Week & Space Technology 1999;151:47-8.
125. Dauer EA. Ethical misfits: Mediation and medical malpractice litigation. In: Sharpe VA, ed. Accountability: Patient Safety and Policy Reform. Washington DC: Georgetown University Press; 2004:185-202.
126. Sharpe VA. Promoting patient safety: An ethical basis for policy deliberation. Hastings Center Report 2003;33:S2-19.
127. Brennan TA, Sox CA, Burstin HR. Relation between negligent adverse events and the outcomes of medical malpractice litigation. New England Journal of Medicine 1996;335:1963-7.
128. Studdert DM, Thomas EJ, Burstin HR, Zbar BI, Orav EJ, Brennan TA. Negligent care and malpractice claiming behavior in Utah and Colorado. Medical Care 2000;38:250-60.
129. Thomas EJ, Studdert DM, Burstin HR, et al. Incidence and types of adverse events and negligent care in Utah and Colorado. Medical Care 2000;38:261-71.
130. Kessler D, McClellan M. Do doctors practice defensive medicine? The Quarterly Journal of Economics 1996;111:353-90.
131. Nagel T. The View from Nowhere. Oxford, UK: Oxford University Press; 1992.
132. HogstaDomstolen. Verdict B 2328-05. In: Court HDSS, ed. Stockholm; 2006:1-6.
133. Christie, N. (2004). A Suitable Amount of Crime. London; New York: Routledge.
134. Becker HS. Outsiders: Studies in the Sociology of Deviance. London: Free Press of Glencoe; 1963.
135. Dauer EA. Ethical misfits: Mediation and medical malpractice litigation. In: Sharpe VA, ed. Accountability: Patient Safety and Policy Reform. Washington DC: eorgetown University Press; 2004:185-202.
136. Vaughan D. The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA. Chicago, IL: University of Chicago Press; 1996.
137. Douglas M. Risk and Blame: Essays in Cultural Theory. London: Routledge; 1992.
138. Snook SA. Friendly Fire: The Accidental Shootdown of US Black Hawks Over Northern Iraq. Princeton, NJ: Princeton University Press; 2000.
139. Galison, P. (2000). An Accident of History. Atmospheric Flight in the Twentieth Century P. Galison and A. Roland. Dordrecht, NL, Kluwer Academic: 3-44.
140. White HB. The Value of Narrativity in the Representation of Reality. Baltimore, MD: Johns Hopkins University Press; 1987.
141. Laudan L. Truth, Error, and Criminal Law: An Essay in Legal Epistemology. Cambridge; New York: Cambridge University Press; 2006.
142. Laudan L. Moral Panics: The Social Construction of Deviance. Oxford, UK: Blackwell; 1994.
143. Cohen S. Folk Devils And Moral Panics: The Creation of the Mods and Rockers. London: Routledge; 1972.
144. Becker HS. Outsiders: Studies in the Sociology of Deviance. London: Free Press of Glencoe; 1963.
145. Cohen 1972, Outsiders: Studies in the Sociology of Deviance.