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Improved Patient Safety

Framework for Addressing Medical Errors

Balancing the Need to Learn from Our Mistakes and the Need for Accountability


David Marx, J.D., President, Outcomes Engineering, LLC.

One of the key issues faced by public and private policymakers is the challenge of promoting a culture in which health care providers and others are willing to come forward with information related to medical errors in a way that allows everyone to learn from mistakes that occur, while at the same time recognizing the need for accountability and, in some cases, disciplinary or enforcement action.

David Marx shared with participants a "Just Culture" framework for considering medical errors and associated responses that included a set of factors for assessing risk-based behavior (purpose, knowledge, recklessness, negligence, and culpability) and an examination of the relationship between types of rule violations and disciplinary action.

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AHRQ Advancing Excellence in Health Care