Just Culture behavior and response
Reports the Just Culture response for a behavior that has already been characterized.
Open the tool → Runs in your browser. Data leaves only if you deliberately send a problem report from the interactive tool.
Example
- The behavior, as already characterized
- Human error - an inadvertent slip, lapse or mistake
- What happened to the patient
- Death
- The same at-risk choice has repeated after coaching
- No
Result: console and examine the system, unchanged by the outcome
The tool opens with these values already filled in. Replace them with your own.
What the result means
- Human error
- An inadvertent slip, lapse or mistake. Console the person and examine the system: process, procedure, training, design, environment.
- At-risk
- A choice whose risk was not seen or was believed justified. Coach: change the incentives and increase situational awareness.
- Reckless
- Conscious disregard of a substantial, unjustifiable risk. Disciplinary action, and it does not depend on how it turned out.
- The outcome
- Changes nothing. Two people who do the same thing get the same response whether the patient was unharmed or died.
- Console
- A response, not the absence of one. Human error is where the system gets examined, and that is where the work is.
- A repeat
- The same at-risk choice after coaching asks whether the coaching changed anything, before escalating.
What you enter
- The behavior, as already characterized
- What happened to the patient (does not change the response)
- The same at-risk choice has repeated after coaching
How this is calculated
Marx D. Patient Safety and the "Just Culture": A Primer for Health Care Executives. New York: Columbia University; 2001. Summarized in the AHRQ Patient Safety Network primer on Culture of Safety. Read the source ↗
A reference and educational tool. Not medical, legal, or financial advice, and not a substitute for clinician judgment.