Just Culture Algorithm

Last week I gave a brief overview of the Just Culture model of accountability. I mentioned the three behaviors to consider with any error: human error, at-risk behavior, and reckless behavior. 

    • Human error is a mistake, a lapse, an inadvertent act. 
    • At-risk behavior is drifting from safe behavior when an individual does not believe the drift would cause any harm. The individual does not recognize the increased risk or believes it is justified. Many of us exhibit at-risk behavior on the highway when we exceed the speed limit (not me of course).
    • Reckless behavior is when an individual has chosen to disregard a substantial and unjustifiable risk. 

The behavior needs to be considered with every error. A human error may indicate an opportunity to correct a system design weakness and the most appropriate course of action may be to console the employee. At-risk behavior may also indicate a system weakness an employee has decided to work around. The system should be reviewed for improvement and the employee may need coaching to recognize the at-risk actions they engaged in.  Reckless behavior, a conscious decision to disregard significant risk, may be grounds for disciplinary action including termination.  

The Just Culture Algorithm will take the manager through questions each manager should ask when evaluating the action which led to the error. Often as managers, we find ourselves jumping straight to something along the lines of “What in the world was he/she thinking? I will need to write them up for their performance” when instead we should be asking more meaningful questions to get to the root of the action prior to determining our next steps. This algorithm puts us in a better frame of mind when interviewing the employee. 

discipline employees

Terri Vidals
Terri Vidals

Terri has been a pharmacist for over 30 years and is a drug diversion mitigation and monitoring subject matter expert. Her years of experience in various roles within hospital pharmacy have given her real-world insight into risk, compliance, and regulatory requirements, as well as best practices for medication and patient safety.

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