interchange
Diamond Member
- Oct 10, 1999
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So we'll take your example.
If they do this 4 or 5 times on the trot do we just go "Oh! Thats just Phil he's got a crappy memory." and let him carry on killing patients? Or do we go "Yeah, Phil. We think that nursing might not be your thing. We're going to have to ask you to find something different."?
Do we punish Phil for the good of society? And would that be a good thing?
A just culture is one that values mistakes. When they happen, you console the person who made the mistake and look to see where the vulnerability is in the system that allowed the mistake to happen. If the vulnerability in the system is that someone is grossly incompetent, then of course you cannot allow them to continue serving that function.
But, a clear pattern of incompetence is not an example of a mistake.
Edit:
This has definitely been studied. More likely than not an error in medicine is found to be caused by faulty systems, processes, or conditions rather than incompetence or recklessness by the person committing the error.
Knowing that, if your response to an error is to punish the person who made the error, how would you ever identify the system, process, or conditions that enabled the error to happen (not to mention basically guarantee that it will happen again)?
And, say someone does commit a mistake that doesn't end up harming someone. How would you know there was a problem until someone died? Do you think, knowing they will be punished, someone will come to you and said they made a mistake and have an idea how it can be prevented in the future?
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