Abstract
A just culture is meant to balance learning from incidents with accountability for their consequences. All the current proposals for just cultures argue for a clear line between acceptable and unacceptable behavior. This alone, however, cannot promote just culture as it falsely assumes that culpability inheres in the act, bearing immutable features independent of context, language or interpretation. The critical question is not where to draw the line, but who gets to draw it. Culpability is socially constructed: the result of deploying one language to describe an incident, and of enacting particular post-conditions. Different accounts of the same incident are always possible (e.g. educational, organizational, political). They generate different repertoires of countermeasures and can be more constructive for safety. The issue is not to exonerate individual practitioners but rather what kind of accountability promotes justice and safety: backward-looking and retributive, or forward-looking and change-oriented.
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References
Alicke MD (2000) Culpable control and the psychology of blame. Psychol Bull 126:556–74
Becker HS (1963) Outsiders: studies in the sociology of deviance. Free Press, New York
Berlinger N (2005) After harm: medical error and the ethics of forgiveness. The Johns Hopkins University Press, Baltimore
Burr V (2003) Social constructionism. Routledge, London
Byrne G (2002) Flight 427: anatomy of an air disaster. Copernicus books, New York
Christie N (2004) A suitable amount of crime. Routledge, London
Cohen-Charash Y, Spector PE (2001) The role of justice in organizations: a meta-analysis. Organ Behav Hum Decis Processes 86:278–321
Cook RI, Render M, Woods DD (2000) Gaps in the continuity of care and progress on patient safety. BMJ 320:791–794
Dauer EA (2004) Ethical misfits: mediation and medical malpractice litigation. In: Sharpe VA (ed) Accountability: patient safety and policy reform. Georgetown University Press, Washington, pp 185–202
Dekker SWA (2003) Failing to adapt or adaptations that fail: contrasting models on procedures and safety. Appl Ergon 34:233–238
Dekker SWA (2007) Discontinuity and disaster: gaps and the negotiation of culpability in medication delivery. J Law Med Ethics 35:463–470
Dekker SWA (2008) Just culture: balancing safety and accountability. Ashgate Publishing Co, Aldershot
Dekker SWA, Laursen T (2007) From punitive action to confidential reporting. Patient Saf Qual Healthc 5:50–56
Douglas M (1992) Risk and blame: essays in cultural theory. Routledge, London
Durkheim E (1950/1895) The rules of the sociological method. Free Press, New York
Erikson K (1966) Wayward puritans. Wiley, New York
Eurocontrol Performance Review Commission (2006) Report on legal and cultural issues in relation to ATM safety occurrence reporting in Europe: outcome of a survey conducted by the Performance Review Unit in 2005–2006. Eurocontrol, Brussels
Ferguson J, Fakelmann R (2005) The culture factor. Front Health Serv Manage 22:33–40
Foucault M (1981) The order of discourse. In: Young R (ed) Untying the text: a post-structuralist reader. Routledge, London, pp 48–79
GAIN (2004) Roadmap to a just culture: Enhancing the safety environment. Global Aviation Information Network (Group E: Flight Ops/ATC Ops Safety Information Sharing Working Group)
Galison P (2000) An accident of history. In: Galison P, Roland A (eds) Atmospheric flight in the twentieth century. Kluwer, Dordrecht, NL, pp 3–44
Green J (2003) The ultimate challenge for risk technologies: controlling the accidental. In: Summerton J, Berner B (eds) Constructing risk and safety in technological practice. Routledge, London
Kohn LT, Corrigan JMK, Donaldson M (eds) (1999) To err is human. Institute of Medicine, Washington DC
Laudan L (2006) Truth, error and criminal law: an essay in legal epistemology. Cambridge University Press, Cambridge
Lerner JS, Tetlock PE (1999) Accounting for the effects of accountability. Psychol Bull 125:255–75
Marx D (2001) Patient safety and the “just culture”: a primer for health care executives. Columbia University, New York
McDonald N, Corrigan S, Ward M (2002 June). Well-intentioned people in dysfunctional systems. Keynote paper presented at the 5th Workshop on human error, safety and systems development, Newcastle
McKenna JT (1999) Criminal and safety probes at odds. Aviat Week Space Technol 47–48 (13 December)
Merry AF, McCall Smith A (2001) Errors, medicine and the law. Cambridge University Press, Cambridge
Morreim EH (2004) Medical errors: pinning the blame versus blaming the system. In: Sharpe VA (ed) Accountability: patient safety and policy reform. Georgetown University Press, Washington, pp 213–232
Nagel T (1992) The view from nowhere. Oxford University Press, Oxford
North DM (2000 May 15) Let judicial system run its course in crash cases. Aviation Week Space Technol, p 66
North DM (2002, February 4) Oil and water, cats and dogs. Aviation Week Space Technol, p 70
Pellegrino ED (2004) Prevention of medical error: where professional and organizational ethics meet. In: Sharpe VA (ed) Accountability: patient safety and policy reform. Georgetown University Press, Washington, pp 83–98
Perrow C (1984) Normal accidents: living with high-risk technologies. Basic Books, New York
Reason JT (1997) Managing the risks of organizational accidents. Ashgate Publishing Co, Aldershot
Rochlin GI (1999) Safe operation as a social construct. Ergonomics 42:1549–1560
Ruitenberg B (2002) Court case against Dutch controllers. The Controller 41:22–5
Sharpe VA (2003) Promoting patient safety: an ethical basis for policy deliberation. Hastings Center Report Special Suppl 33(5):S1–S20
Skegg PDG (1998) Criminal prosecutions of negligent health professionals: the New Zealand experience. Med Law Rev 6:220–46
Smith K (2001) Incompatible goals, uncertain information and conflicting incentives: the dispatch dilemma. Human Factors Aerospace Safety 1:361–380
Suchman LA (1987) Plans and situated actions: the problem of human-machine communication. Cambridge University Press, Cambridge
Ter Kulle A (2004) Safety versus justice. Canso News 18:1–2
Vaughan D (1996) The challenger lauch decision: risky technology, culture and deviance at NASA. University of Chicago Press, Chicago
Vaughan D (1999) The dark side of organizations: mistake, misconduct, and disaster. Annu Rev Sociol 25:271–305
Wiegman D, Zhang H, von Thaden T, Sharma G, Mitchell A (2002) A synthesis of safety culture and safety climate research (Technical report ARL-02-3/FAA-02-2). Aviation Research Lab, University of Illinois, Urbana-Champaign
Wilkinson, S. (1994) The Oscar November incident. Air Space, pp 80–87 (February–March)
Woods DD, Shattuck LG (2000) Distant supervision: local action given the potential for surprise. Cogn Technol Work 2:242–245
Acknowledgment
Part of the work for this paper was conducted on a grant from The European Organisation for the Safety of Air Navigation (Eurocontrol) to study the interface between the judiciary and air navigation service providers. With thanks to Tony Licu and his people in Brussels.
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Dekker, S.W.A. Just culture: who gets to draw the line?. Cogn Tech Work 11, 177–185 (2009). https://doi.org/10.1007/s10111-008-0110-7
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DOI: https://doi.org/10.1007/s10111-008-0110-7