Blatant Negligence vs. Honest Mistakes: Using the Just Culture Framework to Improve Patient Safety
- EvaluCare
- May 25, 2025
- 6 min read
Updated: Dec 5, 2025
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. The difference determines what response an organization should take to prevent it from happening again.
The Just Culture framework is 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 also Just Culture principles when evaluating complex medical care cases. EvaluCare's Eva Software as a Service uses AI technology to assess care. We assess whether what occurred was due to a system failure, human error, or an unacceptable disregard for safety protocols. 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:
Human Error – Unintentional and unpreventable mistakes.
At-Risk Behavior – Behavioral choices that increase risk, often unknowingly.
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-up A 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 Samples A 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 Mistake A 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 Checks A 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 Alarms An 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 Documentation A 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?
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 often where significant patient harm occurs that can lead to medical malpractice, because it can violate the Duty of Care. Reckless behavior represents a willful violation of rules, putting patient safety at significant risk.
Examples of Reckless Behavior:
Example 1: Operating While Impaired A surgeon performs a procedure while under the influence of medication or alcohol, leading to a serious complication.
Example 2: Ignoring Safety Protocols A physician repeatedly ignores infection control measures, even after being counseled, resulting in a hospital-acquired infection outbreak.
Example 3: Performing Unnecessary Surgery A 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.
Using the Just Culture Framework in Medical Care Reviews
When EvaluCare reviews a case, we:
Examine clinical documentation and timelines.
Compare care to clinical standards and guidelines.
Determine the category of the error using the Just Culture model, if indicated through clinical documentation
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
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.
A medical care review can highlight needs with clinical teams to address systems issues.
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.
Learn more about the Just Culture model: https://www.justculture.org
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Eva, EvaluCare’s AI-powered SaaS, delivers quality review for inpatient care by checking adherence to thousands of evidence-based guidelines and protocols. It identifies care gaps, routes clear actions to the right clinicians, and accelerates improvement cycles, strengthening documentation and coding while reducing HACs, HAIs readmissions, length of stay and more. The result is an ROI, starting in the seven figures even for critical access hospitals. Learn more at evalucare.net or contact info@evalucare.net.
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About the Author
Jason Minor is a healthcare quality and transformation leader with nearly 30 years of continuous improvement experience. A Certified Lean Six Sigma Black Belt, Certified Professional in Healthcare Quality, Certified Professional in Patient Safety, and Certified Utilization Review Professional, he has led thousands of end‑to‑end improvement projects, mentored dozens of quality professionals, and pioneered healthcare SaaS innovations.
As Board Chair of the Vermont Program for Quality in Health Care, Jason has partnered with hospitals, non‑profits, and state agencies to elevate patient safety and care quality statewide. Previously, as Network Vice President of Quality at the UVM Health Network and through the Jeffords Institute for Quality, he guided the redesign of a system‑wide quality framework and led initiatives that achieved a number‑one patient safety ranking among the nation’s top academic medical centers.
In 2020, Jason founded EvaluCare to help organizations shift from episodic improvement to a robust quality assurance approach.
EvaluCare’s Eva platform leverages AI‑powered natural language processing, machine learning, and agentic orchestration to analyze and improve inpatient care and support comprehensive quality, mortality, peer, and utilization reviews.
Jason Minor, EvaluCare Executive Director
Network Director Continuous Systems Improvement Jeffords Institute for Quality UVM Health
Board Chair Vermont Program for Quality in Health Care Inc.,
Vice Chair Northwestern Counseling & Support Services, Inc
Lecturer UVM College of Nursing & Health Sciences in Healthcare Quality
Quality Peer Reviewer Vermont Care Partners: Centers of Excellence
