Decision Tree for Unsafe Acts Culpability

Allan Frankel, MD, Principal, Pascal Metrics, Inc. and Faculty, Patient Safety Center, Division of General Medicine, Brigham and Womens Hospital, Boston, Massachusetts, USA



In Managing the Risks of Organizational Accidents, author James Reason provides a decision tree for determining culpability for unsafe acts. This tool is an adaptation of the tree specifically for adverse events.



Use this decision tree when analyzing an error or adverse event that has occurred in your organization, as it may help you identify how human factors and systems issues contributed to the event. This decision tree is particularly helpful when working toward a non-punitive approach in your organization.


**NOTE: It may be helpful to have the following definition for the "Pass substitution test" box in the Decision Tree:


Pass substitution test: Would three (3) other individuals with similar experience and in a similar situation and environment act in the same manner as the person being evaluated?

  • If the answer is "Yes": The problem is not the individual, but more likely the environment that would lead most individuals to that action. (Proceed to the question about a history of unsafe acts.) 
  • If the answer is "No": If similarly experienced individuals would not have acted in a similar manner, it's more likely that the individual being evaluated is more culpable/accountable and in need of action —  whether it is counseling or removal or whatever. (Proceed to the question about deficiencies in training and selection or inexperience.)

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