Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬

Directorate of Health Affairs – Taif ‫مديرية الشؤون الصحية بمحافظة الطائف‬

King Faisal Medical Complex ‫مجمع الملك فيصل الطبى‬
Patient Safety Department ‫إدارة سالمة المرضي‬

Appendix A: Just Culture Algorithm

HUMAN ERROR AT-RISK BEHAVIOR RECKLESS BEHAVIOR

Unintended Actions Intended Action Intended Action
TYPE OF Unintended Consequence Unintended Consequence Intended Consequence
Unpredictable behavior that caused Failure to exercise expected care
BEHAVIOR or could have caused an undesirable
outcome
Inadvertent action: slip, lapse,
mistake, a product of system design
Error Intentional Violation Reckless Behavior/Sabotage
RESULT
Unintentional Violation (Mistake) Intentional Violation for personal gain
STATUS Tolerated Not Tolerated

CORRECTION Product of our current System Design A Choice: Risk believed insignificant or Conscious Disregard of visible & significant
)System will need Re-Design ( justified Unjustifiable Risk

CONSOLE COACH DISCIPLINE

Manage through changes in: Manage through: Manage through:
• Processes • Removing incentives for at risk behavior Remedial
• Procedures • Creating incentives for healthy behaviors and
MANAGMENT • Training • Increasing situational awareness (risk Disciplinary action
• Design perception) (discipline is as per KFMC rules & regulations)
• Environment/ Conditions
• And so on….