This document provides an overview of just culture and accountability in healthcare. It defines just culture as a culture where staff are not punished for actions that align with their training and experience, but gross negligence is not tolerated. The document outlines an algorithm for determining accountability following adverse events. It then provides scenarios and asks the reader to apply the algorithm to determine the type of event or error. The objective is to help practitioners apply just culture principles when responding to safety events.

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Trusted Care:
Just Culture Scenarios

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Objectives
 Given an AFMS Just Culture Algorithm/Case Study,
determine type of event and response to the
associated act
 Given a moral or ethical dilemma, demonstrate
appropriate application of the AF core values
 Given past mishap examples, identify human-factors
“common causes”

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Overview
Definition
Just Culture
Accountability
Adverse Event Overview
Scenarios

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Definition
“Just Culture” is a culture in which
staff are not punished for actions,
omissions or decisions taken by
them which are commensurate with their
experience and training, but where
gross negligence, willful violations,
and destructive acts are not tolerated.
www.eurocontrol.int/articles/just-culture

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Fair and Just Culture
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What Is It?
An atmosphere of trust in which people are
encouraged to provide, and even rewarded for
providing, essential safety-related information, but in
which they are clear about where the line must be
drawn between acceptable and unacceptable
behavior.
James Reason
Managing the Risks of Organizational Accidents (1997)

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Scenario
Amn X comes in for annual cleaning/visit
It is a new clinic with construction and it causes the Airman to be late
Doc Y sees a cavity needs to be filled--patient schedules are limited
Front desk can't book the apt (0 apts)
Doc Y says "come back Thursday during physical fitness time“
Patient walks in Thursday with no scheduled apt
There was no huddle for them to expect the patient
Doc Y is waiting for the patient, his technician SSgt L is surprised and in PT
uniform

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Scenario
Civ tech says she will cover
This is not her normal room
There is no standardization between rooms
There are no surgical kits in the cabinet
Civ tech goes to the Dental sterilization area but the lead tech is on the phone,
she waves her in to get a kit
Carts are not clearly labeled and she grabs a kit
Returns to the room/hurriedly fills the cavity because she is late for her next apt
Later-tech realizes it was not sterilized due to the color of the strip

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Scenario
This is an example of the swiss cheese model
Did one event cause the blocks to tumble?
Was it the last person's fault?
Trying to pinpoint blame--can we ID missing pegs?

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Just Culture
 Just Culture is about communicating expectations:
 Leadership at all levels owns the process
 Practiced and voiced regularly
 Understood by frontline staff

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Accountability
Event
-Blame
-Disciplinary Action
-New Policies
-Lack of standards
-Uncertain accountability
-Fear of reporting
Accountability before event Accountability after event
Attention focused on individual actions vs system failures

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Accountability
Event
-Blame
-Disciplinary Action
-New Policies
-Lack of standards
-Uncertain accountability
-Fear of reporting
I understand what my leaders expect me to do
I understand the duties I am accountable for
I feel safe bringing up safety concerns to my team
I trust leadership not to blame me for system faults
I monitor the actions of my team for unsafe acts
UNJUST
JUST

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Accountability
Event
-Blame
-Disciplinary Action
-New Policies
-Lack of standards
-Uncertain accountability
-Fear of reporting
I understand what my leaders expect me to do
I understand the duties I am accountable for
I feel safe brining up safety concerns to my team
I trust leadership not to blame me for system faults
I monitor the actions of my team for unsafe acts
UNJUST
JUST
Event
-Clear standards
-Clear accountability
-Safe to report
-Fair investigation
-Fair accountability
-Consistent expectations

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Accountability
I understand what my leaders expect me to do
I understand the duties I am accountable for
I feel safe bringing up safety concerns to my team
I trust leadership not to blame me for system faults
I monitor the actions of my team for unsafe acts
UNJUST
JUST
Event
-Clear standards
-Clear accountability
-Safe to report
-Fair investigation
-Fair accountability
-Consistent expectations
Accountability before event Accountability after event
Staff feel psychologically safe…

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IncapacityTest ComplianceTest SubstitutionTest
Were the actions ofthe
staff intentional?
Did the member intendto
cause harm ordamage?
IntentionalAct
Did member depart from
existing policies and
procedures?
Are the policies and
procedures clear AND are
staff aware of and held
accountable for following
them?
Did the member choose
to take an unacceptable
risk or have a history of
risky behaviors?
Would peers with similar
skills under same situation
performsimilarly?
Were there deficiencies in
training, experience,
resources orsupervision?
Were there mitigating
circumstances?
No
No
Yes
No
No
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Modeled after Reason, A Decision Tree for determining the Culpability of Unsafe Acts(1997)
Disciplinary Action
Remove from care
SF/Legal Consultation
Review for:
Administrative Action
Adverse Action
License Board orNPDB
Notification
Highlight AnySystem
Failures identified
Intentional Act ImpairedStaff
If Ill health/medication use:
Adjust/Remove from Duties
If substance abuse:
Refer to ADAPT/Treatment
Contact SF/Legal, consider:
Administrative Action
Adverse Action
License Board notification
Highlight Any System
Failures identified
System
Based Error
Console
Leaders accountable:
Identify system
gaps
Effect improvement
or error proofing
Monitor
performance
Consider RCA/RIE
Unintentional
Error
Disciplinary action
Job Fit Consideration
Consider PIP or
period of supervision
Coach/Mentor
Highlight Any
System Failures
identified
Reckless
Behavior
Console
Coach/Mentor
Educate others
Consider Human
Factors Analysis
Proctor/Supervise
Quality Review
PIP
Highlight Any System
Failures identified
Responses/ActionsTypeContributingFactors/Behaviors
No
EVENT
START
No
No
1
2
Is there evidence of
illness or impairment
due to substance use 3
orabuse?
Ifillness:
Did the individual
know they were in ill
health or had a
medical condition?
If substance related:
Was there a medical
need for the use ofa
controlled substance?4
5
6
7
8 Yes
9
10
No
Yes
Just Culture Algorithm

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Adverse Event Overview
Female patient is being worked up for transient
equilibrium imbalance in an outpatient diagnostic /
treatment procedure room in Radiology (Rad). The testing /
treatment required conscious sedation and pressurized IV
solution into carotid (neck – central line) artery.
During the procedure, the radiology team was
unaware that the patient’s pressurized IV fluid line ran dry.
The patient was inadvertently injected with a large amount
of air (instead of IV fluid) and sustained an air embolism in
the brain, resulting in a stroke.
Patient received rapid assessment and interventions
to successfully treat the embolism. These actions saved
the patient’s life but harm was caused because the patient
sustained irreversible cognitive short-term memory loss.
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Sequence of Events
 Pt arrives in RAD treatment for procedure
 Clinical Nurse certified in conscious sedation sedated the patient
and physician started the procedure
 The physician inserted IV line into femoral (groin) artery and was
advanced up to carotid (neck) artery
 Monitoring of patient’s Vital Signs, pressurized IV fluid was started
by radiology tech and nurse – both responsible for pt monitoring
 Rad Tech 1 was relieved by Rad Tech 2 for lunch relief (handoff was
not performed between Rad Techs)
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Sequence of Events
 Near end of procedure RN noticed pt’s vital signs became
unstable and she displayed seizure-like activity
 The physician was in the room conducting the procedure and
validated the pt’s instability and seizure-like activity
 During management of seizure, the team noted the pressurized IV
bag was empty & IV line was filled with air
 Assessment / treatment for air embolus was initiated
 Patient transferred from Rad to ICU for care
 Before RAD procedure room was closed, the tech erased all
clinical data from the patient monitoring equipment
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Scenario 1
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 It was noted that the Rad Techs:
• Routinely use personal headphones to listen to
music during procedures and, in this case, were
not focused on the IV fluid
 Using the algorithm handout, assess what type of act / error?

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 It was also noted that:
 The nurse set the parameters on the vital signs
monitor
 Physician requested assistance from RN
 The vital signs monitor alarm began ringing
shortly after initiating the procedure and kept
ringing after short periods of silence so Tech 1
disabled the alarm.
 Using the algorithm, assess what type of act / error?
Scenario 2
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 Rad Tech 1 returns from lunch after the patient and
team have moved to the ICU
 Before the patient room is closed, Tech 1 erased all of
the clinical data from the vital signs machine
 Using the algorithm, assess what type of act / error?
Scenario 3
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Final Exercise:
Messaging Just Culture
At your tables, discuss and write
down how you will address these
3 points when you return to your
MTF:
 What can I say to my flight
personnel to foster a Just
Culture?
 How can I get the message out to
them?
 When can I get the message out
to them?
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Objectives
 Given an AFMS Just Culture Algorithm/Case Study,
determine type of event and response to the
associated act
 Given a moral or ethical dilemma, demonstrate
appropriate application of the AF core values
 Given past mishap examples, identify human-factors
“common causes”

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Summary
Definition
Just Culture
Accountability
Adverse Event Overview
Scenarios