Just culture algorithm from the UK National Health Service
Incident decision tree adapted from the UK National Health
Service’s National Patient Safety Agency (NPSA), and a Guide to
Use (from the 2003 version). The National Health Service (NHS)
also issued Guidelines for Action Following Patient Safety
Incidents. This algorithm focuses on identifying whether an
individual was at least partially culpable for the event. The
following is a brief summary of the decision tree, from the NPSA
The Deliberate Harm Test
In most patient safety incidents, the individual had the
patient’s well-being at heart.
However, in some cases the intent was to cause physical or
The Deliberate Harm Test asks questions to help identify or
eliminate this possibility at the earliest possible stage.
The Physical/Mental Health Test
If intent to harm has been discounted, the Physical/Mental Health
Test helps to identify whether the individual’s (not the
patient’s) ill health or substance abuse caused or contributed to
the patient safety incident.
The Foresight Test
If intent to harm and incapacity have been discounted, the
Foresight Test examines whether protocols and safe working
practices were adhered to.
The Substitution Test
Finally, if protocols were not in place or proved ineffective,
the Substitution Test helps to assess how a peer would have been
likely to deal with the situation.