Just and Accountable Culture Algorithm

START Was there a policy to manage this risk?

NO YES Was the policy followed?

YES NO

Are there established

procedures, processes
or structures to manage
this risk that were not
followed?

Does a policy, procedure, process or

structure need to be developed?
NO YES

YES NO
Was the policy/process flawed, inadequate, or difficult to
follow or did the employee lack understanding of the process?

YES NO

Did the employee’s action/inaction contribute to the

error?

NO YES

Were the actions of the employee intended to deliberately harm

the patient and/or employee?
YES

NO

Did the employee conceal the error or falsify the record? YES

NO

SYSTEM FLAW Did the employee consciously take a substantial risk or demonstrate YES
· Error due to flaw in organizational intentional disregard for the policy/process?
system or process
· System or process is well
documented, but system is not NO
appropriate

Is there is history of other similar or serious errors by this

NO employee?

YES
CORRECT SYSTEM FLAW
· Development of policy/ procedure
· System modification
· Documented training Did the employee
Could a reasonably Were mitigating factors
· Positive reinforcement (including previously receive
prudent employee have present that the
thank you) done the same in
remediation or YES organization accepts as
counseling for a similar
similar circumstances? justifiable?
error?

YES NO NO YES NO
Did employee action/inaction also contribute to the
error?

NO YES
HUMAN ERROR AT RISK BEHAVIOR RECKLESS BEHAVIOR
No employee action
needed · Employee has one time lapse, slip or · System or process is well documented · Reckless or willful (conscious)
omission in the performance of their and employee compliance is generally disregard for the safety of a
duties high patient and/or employee
· System or process is well · Error may be the result of substandard · Reckless or willful disregard of
documented, but there is a clear/ performance by a particular employee policy/procedure/process
known practice by a group of through unintentional omission · Willful disregard for organizational
employees which circumvents (in-attention, task saturation, lack of resources
system or process recall) · Willful disregard for organizational
liability and/or reputation
· System modification · Documented education · Failure to adjust behavior/perfor-
· Training · Positive reinforcement (thank you) mance after prior remediation
· Coaching · Coaching
· Documented Education · Re-training · Contact HR
· Positive Reinforcement (thank you) · Contact HR · Possible law enforcement and/or
· Consult with HR as necessary licensing board notification