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More than just blaming: The key to sustainable patient safety

In the first part of our blog series , we learned about the basics of Just Culture as a fair and learning-promoting approach to patient safety and error management in healthcare in Switzerland. We have recognized that Just Culture is in contrast to the traditional blame culture, but this does not mean that no one will be held accountable.

Rather, it is about balanced accountability : a differentiated view of human behavior in order to be able to react appropriately and at the same time uncover systemic vulnerabilities that promote errors (Boysen, 2013).

In this second part of our series, we dive deeper into the heart of Just Culture: the distinction between the three basic behaviors as developed by David Marx (2001) specifically for healthcare. Understanding these categories – human error, risky behaviour and reckless behaviour – forms the foundation for fair incident responses and enables the crucial systemic view that creates sustainable improvements.

Why is this so important?This differentiation is not only theoretically relevant, but has a direct impact on the implementation of reporting systems such as H-CIRS, the psychological safety of employees and ultimately the success of your healthcare error management as well as your safety culture and patient safety.

The three behaviors in detail: Your guide to Just Culture in practice

Imagine: A medication is dosed incorrectly. The decisive question is not “Who was that?”, but “How could this happen?” Was it a simple careless mistake? A deliberate shortcut under time pressure? Or a gross disregard for safety rules? Just Culture provides the structured framework to analyze these questions and respond appropriately.

1. Human error – When competent people work in imperfect systems

Features: Unintentional action without bad intention. An oversight, a slip, a memory gap, a mistake. The person wanted to do the right thing, but the result was not the intention. Human error is often a symptom of systemic problems such as poor design, unclear processes, fatigue, distractions, or inadequate training (Reason, 1990).

Typical practical examples from the Swiss healthcare system:

• Medication errors due to similar-looking packaging or similar-sounding drug names (LASA problem – look-alike-sound-alike) – a well-known phenomenon in pharmacology that affects even experienced professionals.
• Confusion of patient data in confusing IT systems, which is facilitated by complex user interfaces or similar patient names.
• Forgetting necessary steps in rare but critical procedures, especially if they are not performed regularly.
• Misinterpretation of illegible handwritten or unclear instructions that still occur in practice despite digital systems.
• An experienced nurse accidentally administers 10 mg instead of 1 mg of a medication because she misread.
• A surgeon performs an operation on the wrong leg because the patient file was incorrectly labeled.
• A doctor overlooks an important piece of information in the electronic patient record because the system is designed to be confusing.
• A laboratory assistant confuses two samples with similar names.

The Just Culture reaction: Comfort, support and systemic analysis instead of punishment. The affected person needs emotional support, because often the perpetrators themselves suffer the most from the consequences (Marx, 2001). The guiding question is: “How can we design and improve the system in such a way that this error becomes less likely in the future?”

Systemic improvement strategies:

• Standardization and simplification of processes and reduction of disruptive factors, especially for LASA drugs
• User-friendly design of workstations and software
• Intelligent technology as a safety net (e.g. barcode scanner)
• Ergonomic optimization of the working environment
• Optimization of workload and break regulation
• Regular education and training to refresh skills and raise awareness of common sources of failure

Relevance for your practice: Human errors are golden learning opportunities. Effective error management in the healthcare sector and CIRS system such as H-CIRS systematically records these and converts them into concrete system improvements.

2. At-Risk Behavior – When good intentions become dangerous habits

Features: A deliberate decision to deviate from a safe course of action, underestimating the risk or seeing it as justified. Often these behaviors arise from time pressure, practical considerations or because “it has always gone well”. This behavior has often become a habit and may even be tolerated by colleagues or the organization (Marx, 2001).

Typical situations in the Swiss healthcare system:

• Skipping security checks under time pressure
• Elimination of protective equipment because it is cumbersome and impractical
• Abbreviations in the documentation to save time
• Carrying out activities without full qualifications out of helpfulness
• An assistant doctor skips a safety checklist because he is under time pressure and “things have always gone well so far.”
• A nurse does not disinfect her hands between two patients because she is in a hurry and wanted to check something “briefly”.
• A pharmacist declares a medication without a complete identity check because he has known the patient “for a long time”.
• A technician performs maintenance without a safety protocol to save time.

The Just Culture Response: Coaching and Root Cause Research. The person needs to understand why the behavior is risky and what safer alternatives there are. At the same time, the organization must question why this behavior occurs. Are there systemic incentives for the risky behavior? Are the secure processes too complicated or poorly designed? (Marx, 2001; Boysen, 2013)

Systemic solutions:

• Realistic scheduling and resource allocation
• Simplify secure processes
• Eliminating competing priorities
• Positive incentive systems for safe behaviour

Important note: Risky behavior is often a symptom of system problems, not of “problematic” employees. Structured feedback systems such as H-FEEDBACK help to identify these patterns at an early stage and promote a reporting culture in the healthcare sector.

3. Reckless behavior – When boundaries are deliberately crossed

Features: A deliberate disregard for a significant and unjustifiable risk. The person knows that they are taking a high risk, and they do it anyway, for no good reason. This is the rarest category, but also the most serious (Marx, 2001).

Serious examples:

• Repeatedly ignoring safety measures despite admonitions
• Intentional manipulation of documentation
• Working under the influence of alcohol or drugs
• Deliberate endangerment of patient safety or ethical principles
• A doctor operates under the influence of alcohol.
• A nurse repeatedly and deliberately ignores hygiene measures despite repeated warnings.
• A technician deliberately bypasses critical security systems.
• A pharmacist deliberately dispenses expired medication.

The Just Culture reaction: Consistent action up to disciplinary measures. Here, the focus is on individual responsibility , as a line has been deliberately crossed. At the same time, however, it must also be examined whether systemic factors (e.g. lack of supervision, lack of consequences in the past, unclear rules) have enabled or encouraged this behaviour (Marx, 2001).

Leadership Responsibility: Even in the case of reckless behavior, managers must consider the system level . Modern reporting systems such as H-CIRS-Professional support this complex analysis through structured workflows.

The System Glasses: From Individual Behavior to Organizational Improvements

The true strength of Just Culture lies not in the mere categorization of individual actions, but in its systemic perspective. Each of the three behaviors acts as a sensitive diagnostic tool for organizational vulnerabilities, providing valuable clues to potential vulnerabilities in the system (Reason, 1997).

Human Error: Early Warning Indicators of System Problems

Human errors are rarely isolated coincidences, but direct early warning indicators of deeper organizational problems:

• Design flawsin technology and workstations are revealed by recurring operating errors, confusion of similar-looking elements or ergonomic problems.
• Process weaknesses and unclear work instructions manifest themselves in errors in routine activities that are made more difficult by a lack of clarity or contradictory specifications.
• Training gaps and skills gaps become apparent when employees fail in situations for which they should be prepared, but obviously do not have the necessary knowledge or skills.
• Workload and resource scarcity manifest themselves in errors that would not occur under normal conditions, but become practically unavoidable under stress, time pressure or insufficient staffing.

Risky behavior: symptom of problematic systems

Risky behavior is often a desperate attempt to solve problematic systems that force their users to circumvent rules:

• Impractical secure processes lead employees to develop creative but risky workarounds in order to be able to cope with their work at all.
• False incentive systems that prioritize speed and efficiency over safety effectively reward risky behavior and punish conscientious but slower action.
• Discrepancy between theory and practice – the gap between “work-as-imagined” and “work-as-done” (Dekker, 2012) – forces practitioners to find their own solutions, which are often risky but functional in the concrete situation.
• Scarcity of resources or unrealistic expectations create pressures that make safe practices seem like luxuries that cannot be afforded.

Reckless behavior: When systems fail

Even reckless behavior, which is primarily the responsibility of the individual, can be favored or even systematically promoted by organizational factors:

• Lack of supervision and control creates spaces in which reckless behavior remains undetected and can establish itself.
• Unclear or contradictory rules confuse employees and make it difficult to see where the boundaries of acceptable behavior actually lie.
• Weak safety culture sends subtle but impactful messages about what’s really important in the organization and what’s only on paper.
• Lack of consequencesfor rule violationsundermines the credibility of all safety regulations and signals that reckless behavior is tolerated or even accepted.

The transformative paradigm shift

The analysis of incidents in the context of a real Just Culture therefore asks not only “Who did what?”, but above all “Why did it happen?” and “How do we prevent it from happening again?”

This fundamental paradigm shift from person-centered to system-centered analysis is more than just a methodological refinement – it is the key to sustainable improvements in healthcare error management and patient safety. Only by understanding the systemic roots can we develop solutions that not only fix the current problem, but also prevent similar events in the future.

Grey Areas and Challenges in Practice: When Theory Meets Reality

The distinction between the three behaviors sounds very clear in theory, but in practice it often turns out to be a complex challenge. The boundaries, especially between human error and risky behavior, can be fluid (Boysen, 2013). Was the deviation really deliberate? Has the risk actually been recognized and accepted?

The substitution test: A proven tool for fair decisions.

Here, the so-called substitution test proves to be an indispensable instrument (Marx, 2001). This elegant and powerful tool reduces complexity to one central question: “Would another person with comparable qualifications and experience have acted similarly in the same situation?”

• Yes , → rather indicates a human error or a systemically favored risky behavior .
• No, → suspicion is individual, risky or even reckless behavior.

Additional pitfalls in practical application

The application of the Just Culture principles is complicated by other, often underestimated factors.

• Cognitive distortions:Hindsight bias makes situations appear clearer than they were in retrospect (Reason, 1990). What in retrospect appears to be an obvious mistake may have been an understandable decision in the original situation.
• Time pressure:If quick reactions are expected – whether from one’s own organization, authorities or media – there is a risk of hasty judgments that do not do justice to the complexity of the situation (Dekker, 2012).
• Organizational pressure:External factors such as public attention, legal consequences or regulatory requirements can further impair the objective analysis and lead to unbalanced decisions (Khatri et al., 2009).

Secret: Implementing a functional Just Culture requires trained leaders, clear processes , and time for thorough analysis. Modern CIRS systems such as H-CIRS support through structured workflows that automatically remind you of Just Culture principles and promote a systematic approach to error management in healthcare.

Excursus: Professional decision-making aids for managers

For Swiss healthcare institutions of all sizes that want to implement a systematic, standardized approach, the National Patient Safety Foundation (2016) and other leading organizations have developed structured decision-making tools. A particularly practical example is the National Health Service England’s (NHS, 2025) Being Fair Tool, which was developed specifically for the fair assessment of patient safety events and sets international standards for Just Culture implementation.

The NHS Being Fair Tool: A structured best practice approach

This tool represents the current best practice in the Just Culture application and guides leaders through a systematic decision-making process with tests that build on each other:

1. Substitution test:

• Would people from the same specialist group with comparable experience and qualifications have acted in the same way in similar circumstances?
• Was the person involved in relevant training?
• Have experience, background, and cultural differences been taken into account?
• Was the supervision appropriate?

2. Foresight Test:

• Were there clear protocols or accepted practices for the act in question?
• Were these protocols practicable and did they reflect accepted practice?

3. Test for intentional damage:

• Are there any indications of recklessness, willful neglect or intent to cause harm?

4. Fitness test:

• Are there any indications of substance abuse or health problems that could have influenced the actions?

5. Test for extenuating circumstances:

• Are there significant mitigating circumstances for the person’s actions?

Adaptation for Swiss conditions

These structured questions are suitable for complex events in large hospitals as well as for everyday situations in doctors’ surgeries or in long-term care. It is not the size of the health organization that is important, but the systematic, fair approach.

Main element of all decision aids:

• Was the action intentional or unintentional?
• Did the person know the risk?
• Would a comparable person have acted similarly?
• What systemic factors contributed to the situation?
• What improvements are possible?

Modern reporting systems such as H-CIRS-Professional or H-CIRS-Starter can support such approaches through structured workflows and reminder functions , thus promoting a consistent application of Just Culture principles in all areas of healthcare.

Practical tip: This systematic approach is essential for a fair and consistent application of the Just Culture principles. It also forms the basis for effective error management in the healthcare sector. The NHS tool particularly emphasises the importance of a system-based learning response as a basic requirement.

Preparing for Implementation: Your Guide to Practical Implementation

This solid theoretical foundation forms the indispensable basis for practical implementation, which we will deepen in the following parts of our series:

Part 3 will show how to implement Just Culture in your organization – from crucial leadership training to the systematic creation of psychological safety.

Part 4 explains how smart reporting systems such as H-CIRS, H-FEEDBACK, H-IDEE and H-VIGILANCE act as powerful engines of the safety culture and seamlessly implement the Just Culture principles in daily practice.

Part 5 takes a look into the future and shows how Switzerland can learn from international experience and shape a national transformation of the healthcare system.

 

Conclusion: Just Culture as a strategic competitive advantage for Swiss healthcare organizations

The differentiated view of human error, risky and reckless behavior is much more than a theoretical exercise – it is the main building block of a successful, sustainable safety culture. Organizations that master this distinction and apply it systematically gain decisive advantages and move towards what Wachter (2012) describes as a “High Reliability Organization” – an organization that achieves exceptionally high security standards through a systemic safety culture and continuous learning:

• Increased patient safety through targeted systemic improvements
• Strengthened employee trust and the associated higher willingness to report
• Improved error culture with continuous learning ability
• Cost reduction through error prevention
• Compliance advantages for regulatory requirements

 

Your strategic next step: Take an honest look at your current practice. How does your organization actually respond to incidents? Is there already a differentiated analysis and fair decision-making, or does the reflexive apportionment of blame still dominate? This self-reflection is the first, crucial step on the way to a transformative Just Culture, which develops your organization from a reactive to a proactively learning system.

References

Boysen, P. G. (2013). Just Culture: A Foundation for Balanced Accountability and Patient Safety. The Ochsner Journal, 13(3), 400–406. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3776518/

Dekker, S. (2012). Just Culture: Balancing Safety and Accountability. Ashgate Publishing. https://www.taylorfrancis.com/books/mono/10.4324/9781315251271/culture-sidney-dekker

Khatri, N., Brown, G.D., & Hicks, L.L. (2009). From a blame culture to a just culture in health care. Health Care Management Review, 34(4), 312–322. https://doi.org/10.1097/HMR.0b013e3181a3b709

Marx, D. (2001). Patient Safety and the “Just Culture”: A Primer for Health Care Executives. New York, NY: Trustees of Columbia University. https://psnet.ahrq.gov/resources/resource/1582/patient-safety-and-the-just-culture-a-primer-for-health-care-executives

National Health Service England. (2025). Being fair tool: Supporting staff following a patient safety incident.

https://www.england.nhs.uk/wp-content/uploads/2025/05/prn01822-i-being-fair-tool.pdf

National Patient Safety Foundation. (2016). A Just Culture Tool. https://zdoggmd.com/wp-content/uploads/2018/12/Just-Culture-Tool_NPSF-Version_Adelman_9_22_16.pdf

Reason, J. (1990). Human error. Cambridge University Press. https://www.cambridge.org/highereducation/books/human-error/281486994DE4704203A514F7B7D826C0#overview

Wachter, R. M. (2012). Understanding Patient Safety (2nd ed.). McGraw-Hill Education.

https://www.amazon.de/Understanding-Patient-Safety-Robert-Wachter/dp/0071765786

 

Ready for change?

new-win supports you on your way to Just Culture

Implementing a Just Culture starts with the right understanding – but it also needs the right tools and experienced partners. As a leading provider of reporting systems in the Swiss healthcare sector, we at new-win understand the practical challenges of implementing Just Culture.

Our solutions for your Just Culture transformation:

• H-CIRS-Professional – Comprehensive reporting system for seamless Just Culture integration
• H-FEEDBACK – Structured feedback for continuous improvement
• H-IDEE – Innovative idea management for proactive safety culture and employee engagement
• H-VIGILANCE – Simple vigilance reporting system for materio, pharmacovigilance and hemovigilance cases

 

Why new-win is the right partner for your error management in the healthcare sector:

• Swiss expertise – specially developed for the requirements of the Swiss healthcare system
• Scalable solutions – Just Culture integration regardless of the size of the organization
• Proven implementation – successfully implemented in leading healthcare organizations
• Continuous development – based on the latest findings

 

For in-depth insights and training , we recommend our partner PD Dr. med. Sven Staender, the pioneer of patient safety in Switzerland.

Contact us for a non-binding conversation! Learn how we can support you on your journey to greater patient safety and an open learning culture .