Just Culture

Just Culture | Concepts & Definitions

  • Focus on evaluating the behavioral choices made by an individual, not on the outcome of the event; 
  • Require leadership commitment and modeling; 
  • Distinguish among normal human error, unintentional risk-taking behavior, intentional risk-taking behavior, and reckless behavior; 
  • Foster a learning environment that encourages reporting (including self-reports) of all near misses, mistakes, errors, adverse events, and system weaknesses; 
  • Lends itself to continuous improvement of work processes and systems to ensure the highest level of client and staff safety; 
  • Encourage the use of non-disciplinary actions whenever appropriate (including coaching, counseling, training, and education); 
  • Hold individuals accountable for their own performance in accordance with their job responsibilities; and, 
  • Does not expect individuals to assume accountability for system flaws over which they had no control.


Terms, Definitions and Examples

Human Error

Not reportable to NCBON

  • Nurse inadvertently, unintentionally did something other than intended or other than what should have been done; 
  • A slip; 
  • A lapse; or 
  • An honest mistake. 
  • Isolated event, not a pattern of behavior.

(Repetitive human error or pattern of behavior requires further evaluation)


  • Single medication event/error (wrong dose, wrong route, wrong patient, or wrong time) 
  • Failure to implement a treatment order due to oversight 

Responses to Behavior:

  • Consoling or Coaching
At-Risk Behavior

Board of Nursing Practice Consultant to be contacted for consultation


  • Behavioral choice that increases risk where risk may not be recognized or is mistakenly believed to be justified; 
  • Nurse does not appreciate risk; 
  • Unintentional risk taking; and 
  • Nurse’s performance or conduct does not pose a continuing practice risk to clients or others. 

(Repetitive at-risk behavior or pattern of behavior requires further evaluation)


  • Exceeding scope of practice 
  • Pre-documentation 
  • Minor deviations from established procedure 
  • Nurse knowingly deviates from a standard due to a lack of understanding of risk to client, organization, self, or others

Responses to Behavior:

Coaching or Counseling

  • If behavior not a pattern of practice) to raise awareness of accepted procedures and potential risks for failure to comply 
  • Remedial actions taken may include education, training, and assignment of activities appropriate to knowledge and skill 
  • Nurse may be informed failure to change is not an option 
  • If nurse does not accept coaching, may result in disciplinary action

Board Action:

  • Non-disciplinary Remediation 
  • Disciplinary Action if Indicated
Reckless Behavior

Mandatory report to Board or Nursing required.


  • Nurse consciously disregards a substantial and unjustifiable risk; 
  • Nurse's action or inaction is intentional and purposeful; or 
  • Nurse puts own self/personal interest above that of client, organization or others


  • Nurse abandons patients by leaving workplace before reporting to another appropriately licensed nurse. Nurse leaves workplace before completing all assigned patient/client care (including documentation) for a non-urgent reason. 
  • Nurse does not intervene to protect a patient because nurse is not assigned to patient 
  • Nurse makes serious medication error, when realized tells no one, and when questioned denies any knowledge of reason for change in client condition 
  • Nurse falsifies documentation to conceal an error

Response to Behavior:

  • Report to Board for Investigation 
  • Disciplinary Action by Board
Additional Definitions

Consoling – affording comfort or solace; restoring confidence and relieving anxiety.

Coaching – supportive discussion with an employee on the need to engage in safe behavioral choices.

Counseling – a first step in disciplinary action; putting an employee on notice that performance is unacceptable.

Last Changed: 14-March-2024