Blatant Negligence vs. Honest Mistakes: Using the Just Culture Framework to Understand Medical Malpractice

When it comes to medical errors, distinguishing between blatant negligence and an honest mistake is not just a moral question, it’s a legal and clinical one. Just Culture is a framework to evaluate the level of negligence in a medical error. that led to patient harm.

When a medical error causes harm, families and patients are left asking an overwhelming and emotional question: "Was this an unavoidable mistake, or did someone act negligently?"

Distinguishing between blatant negligence and an honest mistake is not just a moral question, it’s a legal and clinical one. The difference can determine whether a medical malpractice claim is valid, and more importantly, whether the system must change to prevent it from happening again.

This is where the Just Culture framework becomes essential. Adopted widely in healthcare settings, this model helps organizations understand the underlying causes of errors and differentiate between system flaws and reckless behaviors. It provides a structured way to respond to adverse events, balancing accountability with learning and continuous systems improvement.

At EvaluCare, our team of seasoned healthcare professionals and medical reviewers applies the Just Culture principles when evaluating complex medical care cases. We assess whether what occurred was due to a system failure, human error, or an unacceptable disregard for safety protocols, and help patients determine the appropriate next steps, including legal action if warranted. This evaluation isn’t as clear cut as it might seem, it involves having essential knowledge of acceptable standards of care. This is best done by a team of practicing quality and medical professionals who have lead the health system in positions where they routinely do this evaluation.

Let’s explore the Just Culture framework and how it applies to real-world healthcare errors.

What is the Just Culture Framework?

Just Culture is a model developed to help organizations differentiate between:

1. Human Error – Unintentional and unpreventable mistakes.

2. At-Risk Behavior – Behavioral choices that increase risk, often unknowingly.

3. Reckless Behavior – Conscious disregard for substantial and unjustifiable risk.

This framework is widely used in hospitals, aviation, and other high-stakes industries to promote accountability without instilling fear, ensuring learning and systemic improvements instead of punitive reactions. It helps the evaluator understand the systems issues at play. It is a blame-free approach that uses accountability and system awareness as a means to determine event significance.

1. Human Error – Honest Mistakes

Definition: An inadvertent action; inadvertently doing something other than what should have been done; a slip, lapse, or mistake.

These are the "oops" moments, like selecting the wrong medication due to a look-alike label or accidentally entering the wrong dosage in an electronic medical record. Importantly, these are not the result of negligence or willful disregard but of human limitations, impacted by human factors.

Examples of Human Error:

Example 1: Medication Mix-upA nurse accidentally administers 10mg of a medication instead of 1mg due to a decimal point error in the EMR. The error was caught early, and the patient was monitored with no lasting harm.

Example 2: Mislabeling of Lab SamplesA lab technician mislabels a blood sample due to distraction, leading to a delay in diagnosis. Upon discovery, the facility immediately initiates a review and implements double-check procedures.

Example 3: Fatigue-Related MistakeA physician on a 24-hour shift forgets to order a standard follow-up test post-surgery. The oversight delays the patient's discharge but does not cause long-term harm. (In this example “forgets” is much different than if a physician knowingly “forgos” an order to save time.)

How Just Culture Responds:

Focus is on system improvements, not punishing the individual. Investigate how to reduce distractions, manage workloads, and improve safety checks.

2. At-Risk Behavior – A Gray Area

Definition: A behavior that increases risk where the risk is not recognized, or is mistakenly believed to be justified.

This type of behavior is often seen in environments with high pressure, poor training, or normalized shortcuts. These are more than honest mistakes but less than intentional negligence.

Examples of At-Risk Behavior:

Example 1: Skipping Patient ID ChecksA nurse skips checking a patient’s ID bracelet because they “know the patient well,” resulting in the wrong patient receiving a medication.

Example 2: Bypassing AlarmsAn ICU technician disables a patient alarm that is frequently triggered without checking the patient’s status, leading to a missed cardiac event.

Example 3: Incomplete DocumentationA physician routinely omits detailed notes in the medical record, assuming the verbal handoff is sufficient. As a result, a critical allergy is missed by the next team.

How Just Culture Responds:

This calls for coaching and system redesign. The goal is to understand why these behaviors are occurring. Was it a time pressure issue? Training? Culture?

These are the kinds of issues EvaluCare looks at closely when reviewing medical care and even supporting direct settlements or supporting attorneys with a discovery strategy: Are these behaviors a reflection of systemic culture or individual disregard?

3. Reckless Behavior – Blatant Negligence

Definition: A conscious disregard of substantial and unjustifiable risk.

This is where medical malpractice cases often arise. Reckless behavior represents a willful violation of rules, putting patient safety at significant risk.

Examples of Reckless Behavior:

Example 1: Operating While ImpairedA surgeon performs a procedure while under the influence of medication or alcohol, leading to a serious complication.

Example 2: Ignoring Safety ProtocolsA physician repeatedly ignores infection control measures, even after being counseled, resulting in a hospital-acquired infection outbreak.

Example 3: Performing Unnecessary SurgeryA specialist convinces a patient to undergo a complex spinal surgery without discussing conservative alternatives, motivated by financial incentives, resulting in permanent damage.

How Just Culture Responds:

This behavior warrants disciplinary action, including license review or up to termination. There’s no system fix for this level of willful disregard. It’s about removing dangerous individuals from the care environment.

This is where EvaluCare steps in to support patients and families in building strong malpractice claims backed by clinical reviews showing reckless behavior. This level of knowledge can come out when discussing the error with other caregivers who may indicate provider issues. This level of discovery most often occurs in preparing a case for trial.

Using the Just Culture Framework in Medical Malpractice Review

When EvaluCare reviews a case, we:

1. Examine clinical documentation and timelines.

2. Compare care to clinical standards and guidelines.

3. Interviews patients or families (when applicable).

4. Determine the category of the error using the Just Culture model.

This allows us to distinguish:

• A mistake that happened despite proper precautions

• A pattern of risky behavior left unchecked

• A reckless act that demands accountability

Generally, Reckless Behavior or gross At-Risk Behavior leading to patient harm (as a result of the negligence) typically meets the threshold for medical malpractice.

Hypothetical Case Study Example

Let’s walk through a care scenario.

The Case:

A 68-year-old woman undergoes knee replacement surgery. Post-op, she experiences chest pain and confusion. A nurse documents it but doesn’t notify a physician, assuming it’s normal post-op pain.

She later goes into cardiac arrest. A review shows she had a pulmonary embolism.

EvaluCare Analysis:

• Human Error: The nurse forgot to elevate the patient’s legs post-surgery, a standard preventive measure.

• At-Risk Behavior: The nurse failed to notify the physician of chest pain, assuming it wasn’t urgent, a risky shortcut.

• Reckless Behavior: The hospital had no policy for post-op embolism screening, despite known high risk. Leaders had been warned, but didn’t act. Other cases at the hospital later discovered illustrate a pattern of occurrences. Reviewing hospital policy against known standards of care and practice guidelines established hospital negligence.

This multi-layered failure can inform a malpractice claim, especially if reckless disregard by the institution or its leaders is established.

How EvaluCare Can Help

At EvaluCare, we specialize in medical care reviews by quality and medical professionals who have worked inside and led hospital and health systems quality, safety, and risk programs. Our approach is compassionate, objective, and built on decades of experience. We help patients and families by:

• Identifying what kind of error occurred

• Explaining why and how it happened

• Evaluating the strength of a malpractice case

• Recommending next steps, including legal options or negotiations

We bridge the gap between confusion and clarity, helping individuals understand their rights and recourse.

Summary

Understanding the difference between blatant negligence and an honest mistake is crucial in evaluating medical malpractice. The Just Culture framework offers a structured, evidence-based way to assess these events, one that health systems and independent reviewers like EvaluCare use to guide decisions.

Patients and families deserve to know what happened, and why. Whether it’s to pursue legal action or to simply gain peace of mind, EvaluCare is here to help you find answers.

Learn more about the Just Culture model: https://www.justculture.org

Visit EvaluCare for a compassionate review of your medical care: https://www.evalucare.net