Appendix C: Just Culture – Decision Tree

Human Error At Risk Bhavior Reckless Behavior

BEHAVIOUR TYPE Exceptional Expected
Unintentional Unintentional Organizational Personal
è Behavior Behavior Situational Optimizing
Reckless
Error(Slip, Lapse, Error(Slip, Lapse, Routine Violation Optimizing Violation
Violation Violation Violation
or Mistakes) or Mistakes)
Did the team Did the team member
Were procedures Do other team Did the team Did the team vary intentionally not follow
Did the team Were all Did the team member think there
unclear or not members normally member think the from the procedure
the procedure without
Team Member member go above procedures and member think they was some benefit for thinking or caring about
workable and/or not follow procedure was a to make it easier
Behavior & beyond call of instructions were doing things the hospital by doing the consequences?
Defective Training procedures in the barrier to getting for themselves?
duty? followed? the right way? the job a different
& Experience? same way? the job done?
way?
START è
* Yes * No * Yes * No * Yes * No * Yes * No * Yes * No * Yes * No * Yes * No * Yes * No * Yes
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□ System produced □ Does, this happen □ Coach the team
□ Coach the team member on balancing
□ Recognition or error needing often? □ Console team
□ Refer to Medico- □ Refer to Medico-
member on work and time
reward correction of root (If yes ,routine members on
speaking up when pressure with Legal Affairs Legal Affairs
□ Record on causes error & record for importance of
procedures cannot hospital values. Department for Department for
employee file trend analysis) following correct
Team Member be followed and Formal Disciplinary Formal disciplinary
□ Convey cause of □ Console person procedures and not □ Consider
Consequence □ No Action delaying the job action in action in
recognition to on correct □ HERF by Head/ taking short cuts. disciplinary measures
until it can be accordance with accordance with
department procedures Supervisor where appropriate, If
completed safely relevant relevant
members □ Re-orientation for risk exceeded benefit procedures. procedures
□ Copy to Direct □ Console person all members on □ Records on
□ HERF by Head/
Supervisor on taking more procedures employee file
Supervisor
care.

Did the Head/ Did the Head/

Did the Head/
Does theHead/ supervisor know Does the Head/ Supervisor know Did the Head/
Head of Did the Head/ Supervisor authorize Did the Head/
Did the Head/ Supervisor lead by the procedure was supervisor not the procedure was a Supervisor not
Department/ Supervisor think the shortcuts or other Supervisor condone
Supervisor also example by unclear or not always ensure work barrier to getting manage the
Supervisor task was being non- approved or ignore the
exhibit exceptional complying with workable and/or is completed in the the job done variance/behavior
completed in the methods thinking this actions of the team
Behavior behavior? procedures and Defective Training appropriate and however managed on this or previous
required manner? was a benefit for the member?
instructions? & Experience ? correct manner? the matter occasions?
hospital?
START è appropriately?

* Yes * No * Yes * No * Yes * No * Yes * No * Yes * No * Yes * No * Yes * No * Yes * No * Yes

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□ Recognition or □ Refer to Medico- □ Refer to Medico-
□ Review procedure
reward. Legal Affairs Legal Affairs
□ Console on how for possible defects □ Consider leadership
□ Does this happen training Department for Department for
to monitor, □ Console on how
□ Record on often?(if yes, Formal disciplinary Formal disciplinary
evaluate & enforce to monitor, □ Coaching on how
Head of employee file routine error & action in action in accordance
procedures. evaluate & enforce to monitor, evaluate
record for trend accordance with with the relevant
Department/ □ No Action procedures. & enforce □ Formal disciplinary
□ Convey cause of analysis) relevant procedures.
Supervisor required □ leadership skills procedures. action in accordance
recognition to procedures. □ Coaching on
Consequence training □ leadership skills with relevant
department □ Console □ Coaching on how importance of not
training □ leadership skills procedures
members employee on taking to recognize the to condone &
training □ Record on
more care. deal with such seriously consider
□ Copy to Direct employee file behavior earlier. such behavior.
Supervisor