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Just culture algorithm from Outcome Engenuity

This algorithm, developed by Outcome Engenuity and David Marx, focuses on duty and mechanism of error.

According to this algorithm, there are three basic duties:

  1. Duty to produce an outcome. If an individual knows the desired outcome and should be able to produce it (e.g., safe removal of an inflamed appendix), failure to do so represents breach of this duty.
  2. Duty to follow a procedural rule. If the individual knows the proper procedure and it is possible to follow the rule (e.g., the procedure for inserting a central venous catheter), failure to do so represents a breach of this duty.
  3. Duty to avoid causing unjustifiable risk or harm. Breach of this duty occurs when an individual intentionally harms the patient or acts recklessly.

If a duty has been breached, then the mechanism of the breach is identified. There are three identified causes:

  1. Human error. This is an inadvertent act (“slip,” “lapse” or “mistake”).
  2. At-risk behavior. Typically, this is a conscious drift from safe behavior, occurring when an individual believes that drift doesn’t cause any harm. An everyday example is the willingness of some drivers to roll through stop signs. Those drivers do not see that as risk-taking behavior, as, in their experience, nothing bad happened consequently.
  3. Reckless behavior. In this case, the individual has chosen conduct that he knows poses a substantial and unjustifiable risk.

The response to an event (or near miss) is tied to the mechanism of error. An isolated human error is an opportunity to correct system weaknesses (e.g., confusing drug labels). The individual making the error should be consoled, rather than disciplined. At-risk behavior may also indicate a system vulnerability that should be fixed. However, the individual should be coached so that he understands the risks he has taken. Reckless behavior may be grounds for disciplinary action. The intent is to reduce the risk of future reckless conduct, and may include removing the individual from the organization.

Repetitive problems are often caused by system weaknesses, but sometimes are individual performance issues, particularly when coaching or additional training has not improved the problem. For example, repetitive human errors may be an indication that the individual is not capable of performing safely in his current job. Repetitive at-risk behaviors may be due to impairment (e.g., drug abuse) or unwillingness to follow proper protocols.