- The table below should be used to help ensure appropriate application of Just Culture principles and aid in determining the right course of action when there has been an error, near miss, adverse event or unexpected outcome, or when a Workforce Member has otherwise not met his/her obligations to the organization.
- Supervisors, managers, and Workforce Members may consult with departmental and facility patient safety, risk management, and human resources/performance management personnel, Just Culture Champions, and Labor Union partners (as applicable) for guidance and support as needed in using the Just Culture System and Behaviors Response Guide.
| ERROR AND BEHAVIORAL CHOICES | RESPONSE TO SYSTEMS AND INDIVIDUALS | | Human Error
(inadvertently doing other than what should have been done: a slip, lapse, or mistake) | -
Evaluate for system contributors (includes results of substitution test, presence of existing policies and procedures that promote expected behavior, and availability of resources, suitable education, and training). -
Determine the organization’s tolerance to risks related to the Human Error. -
Work with staff to redesign the system or its components to prevent and/or mitigate unintended risks or harm. -
Coach and Console individual. -
If there is history of similar human errors by the same individual, add Counseling and/or Remedial Action. -
Repetitive Human Error may rise to the level of At-risk Behavior. | | Justifiable Choice
(behavioral choice that may be inconsistent with Departmental policy and expectations, but is justified in an effort to protect patients and/or Human and Departmental resources) | -
Evaluate for system contributors (includes results of substitution test, presence of existing policies and procedures that promote expected behavior, and availability of resources, suitable education, and training). -
Determine the organization’s tolerance to risks related to the Justifiable Choice. -
Work with staff to redesign the system or its components to prevent and/or mitigate unintended risks or harm. -
Coach and Console individual. -
If there is history of similar justifiable choice by the same individual, add Counseling and/or Remedial Action. -
Repetitive Justifiable Choice may rise to the level of At-Risk Behavior | | At-Risk Behavior
(behavioral choice that increases risk where risk is not recognized, or mistakenly believed to be justified, may include repeated acts of similar human error and/or justifiable choice. | -
Evaluate for system contributors (includes results of substitution test, presence of existing policies and procedures that promote expected behavior, and availability of resources, suitable education, and training). -
Determine the organization’s tolerance to risks related to the At-Risk Behavior. -
Work with staff to redesign the system or its components to prevent and/or mitigate unintended risks or harm. -
Assess if there are incentives for At-Risk Behavior. -
Establish clear expectations with the individual who made this behavioral choice which may include placing or changing incentives and consequences to discourage undesirable behavioral choices and encourage desirable behavioral choices. -
Counsel and provide Remedial Action. -
If there is history of similar At-risk Behavioral Choices by the same individual, add additional Remedial Actions and/or Disciplinary Action (as applicable). -
Repetitive At-risk Behavior may rise to the level of Reckless Behavior. | | Reckless Behavior
(behavioral choice to consciously disregard; a substantial and unjustfiable risk; may include repeated acts of at-risk behavior) | -
Take immediate steps to stop the individual from engaging in further Reckless Behavior. -
Evaluate for system contributors (includes results of substitution test, presence of existing policies and procedures that promote expected behavior, and availability of resources, suitable education, and training). -
Determine the organization’s tolerance to risks related to Reckless Behavior. -
Work with staff to redesign the system or its components to prevent and/or mitigate unintended risks or harm. -
Assess if there are incentives in Reckless Behavior. -
Establish clear expectations with the individual who made this behavioral choice which may include placing or changing incentives and consequences to discourage undesirable behavioral choices and encourage desirable behavioral choices. -
Consult with management regarding the need for disciplinary action (as applicable). | | Beyond Reckless (Malicious Action)
(behavioral choice with deliberate intent to harm another individual. It is malevolent and motivated by wrongful, vicious, or mischievous purposes) | | | |
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