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.
