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Statement of Support for a Statewide Culture of Learning Justice and Accountability

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Given that:

  • Medical errors and patient safety are a national concern to all involved in health care delivery. 

  • We are legally and/or ethically obligated to hold individuals accountable for their competency and behaviors that impact patient care. 

  • A punitive environment does not fully take into account systems issues, and a blame-free environment does not hold individuals appropriately accountable.

We resolve that our organization will:

  • Strive for a culture that balances the need for a non-punitive learning environment with the equally important need to hold persons accountable for their actions. 

  • Seek to judge the behavior, not the outcome, distinguishing between human error, at-risk behavior, and intentional reckless behavior. 

  • Foster a learning environment that encourages the identification and review of all errors, near-misses, adverse events, and system weaknesses. 

  • Promote the use of a wide range of responses to safety-related events caused by lapses in human behavior, including coaching, non-disciplinary counseling, additional education or training, demonstration of competency, additional supervision and oversight and disciplinary action when appropriate to address performance issues. 

  • Support and implement systems that enable safe behavior to prevent harm. 

  • Work to share information across organizations to promote continuous improvement and ensure the highest level of patient safety and staff safety. 

  • Collaborate in efforts to establish a statewide culture of learning, justice, and accountability to provide the safest possible environment for patients.

Adopted:  June 2006
Reaffirmed:  October 2009