Patients Come First

David Marx from Outcomes Engineering has a new book out that provides great details of the concepts we discussed at the forum on March 25, 2009-Creating a Just Culture.  His book is called “Whack-a-Mole” and outlines the concepts of duty and breach as it applies to every day life and als to high risk professions.  I continue to ponder the issue he addresses over and over regarding the behavior versus he outcome and how we as a society focus on the outcome when we judge it to be significant while minimizing the behavior that lead to the outcome.  He uses the example of the driver who is drunk but makes it home without a problem compared the the driver who is drunk and is an accident and hurts or kills someone.   Both made a behavioral choice to drive while impaired but we judge and punish the one that hurts someone more harshly. More information here.

Patients (and we are all patients at some point) assume that clinicians providing care do so with the patients’ best interest in mind so that the care is appropriate and will make the pateints better.  They asume quality.  How do we as colleagues, peers, leaders and administrators repoond when we know that the duty to do no harm or deliver on an outcome (appropriate care) did not occur?  We must act. The Just Culture paradigm Marx presented at the forum is a excellent tool.  Learn more about Marx’s paradigm here.