Reckless Behaviour and Just Culture Accountability

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Reckless behavior

Definition. Reckless behavior is the conscious disregard of a substantial and unjustifiable risk. In comparison to at-risk behaviors, individuals who behave recklessly always know the risk they are taking and understand that it is substantial. They behave intentionally and are unable to justify the behavior (i.e., do not mistakenly believe the risk is justified). They know others are not engaging in the behavior (i.e., it is not the norm). The behavior represents a conscious choice to disregard what they know to be a substantial and unjustifiable risk. Key to this concept is that the individual must recognize the substantial and unjustifiable risk in order to disregard it. Therefore, they must reasonably foresee that their actions or inaction will or could create a substantial and unjustifiable risk. 

Causes and examples. The reasons for engaging in reckless behavior are as varied as the conduct, but no reason can excuse recklessness towards the safety of others. While reckless behavior is hopefully rare, examples include drug diversion, retaliatory breaches in patient confidentiality, or performing surgery under the influence of drugs or alcohol. 

Differentiating between at-risk and reckless behavior. Some organizations have difficulty distinguishing between at-risk and reckless behavior. To be clear, when determining whether the behavior is reckless, the question to ask yourself is whether the individual consciously disregarded what he or she knew to be a substantial and unjustifiable RISK. This question is associated with the conscious disregard of a known substantial and unjustifiable RISK, not the conscious disregard of a policy, procedure, or usual practice standard. Policy, procedure, and practice standard violations are often at-risk rather than reckless choices, where the RISK is not seen or mistakenly believed to be insignificant or justified. Reckless behavior requires the conscious disregard of a perceived significant RISK. Most often, the person making a reckless choice is motivated by a self-centered desire to put their own needs ahead of others; thus, their behavior has no social utility to benefit others, particularly the patient, the organization, or their colleagues. Differences between at-risk and reckless behaviors are summarized in Table 1

At-Risk BehaviorReckless Behavior
Perception
Does not see the risk OR mistakenly believes the risk is insignificant or justifiedAlways perceives the risk AND understands that the risk is substantial and not justified
Behavior is often the norm within groupsKnows the behavior is not the norm within groups
Risk monitor does not alarm—mistakenly believes the choice is safeRisk monitor alarms—knows the choice is unsafe
Does not consciously disregard what is known to be a substantial and unjustifiable RISKMakes a conscious choice to disregard the substantial and unjustifiable RISK
Motivation
Behavioral choice is often patient-, colleague-, or organization-centric (desire to help others)Behavioral choice is often self-centered (desire to help oneself)
Puts patients, colleagues, organization firstPuts own needs ahead of others
Decision has social utilityDecision has no social utility

Management. In a Just Culture, reckless behavior is blameworthy behavior. As such, swift and appropriate remedial or disciplinary actions should be considered according to the organization’s human resources policies to correct the undesired conduct. The level of corrective action is typically determined by the organization’s disciplinary procedures and often ranges from counseling or reprimand to more punitive actions such as termination of employment. Additionally, system redesign may be helpful to protect against future reckless behavior. For example, drug diversion can be curbed with robust system enhancements. 

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