Outcome Engenuity, LLC was founded in 1997 by CEO David Marx, a pioneer of the Just Culture movement. The firm originally addressed safety issues and human factors in aviation and offered expertise in post-event investigation and analysis. With the unique combination of systems engineering, human factors, and the law, Marx adopted and expanded the concepts of ‘Just Culture’ to help improve the management of human error.
Spurred by the Institute of Medicine’s 1999 seminal study, To Err Is Human: Building a Safer Health System, and recognizing the need for a Just Culture approach, Outcome Engenuity began focusing on healthcare. The study showed that 98,000 people died annually from medical errors – a number which has only increased in the intervening years. In 2003, Marx wrote “Patient Safety and the ‘Just Culture’: A Primer for Health Care Executives” for the National Institutes of Health.
For more than two decades Outcome Engenuity has advanced the concept of Just Culture and its role in the design of effective socio-technical systems. We integrate systems engineering, human factors science, and even the law into unique strategies that help organizations transform to a Just Culture, effectively investigate events, and manage risk.