American Association for Clinical Chemistry
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Patient Safety Focus: How to Modify Staff Behavior That Puts Patients At Risk


How to Modify Staff Behavior That Puts Patients At Risk The Just Culture Model
The Just Culture Model

James Hernandez, MD, MS

Assistant Professor, Medical Director of Laboratories, and Chair of the Division of Clinical Pathology
Department of Laboratory Medicine and Pathology, Mayo Clinic Arizona
Scottsdale and Phoenix, Ariz.

Q: We have a lab employee who is repeatedly taking shortcuts in performing a test procedure and this is putting patients at risk. Many of us know this is going on and the employee has been warned many times by coworkers and management, but nobody, including management, has the backbone to resolve the situation with this “unsafe” employee. Can you advise us?

A: In our practice we have implemented the principles of the “Just Culture,” as described by David Marx (1). According to Marx, errors can be divided into three categories and the response by management depends on the type of error. If the action was inadvertent, a so-called slip, lapse or mistake, then consoling is indicated. If the employee is engaging in at-risk behavior, defined as a “behavioral choice that increases risk where risk is not recognized or is mistakenly believed to be justified,” then coaching is the appropriate response (3). On the other hand, if the employee is engaging in reckless behavior, defined as a “behavioral choice to consciously disregard a substantial and unjustifiable risk,” then the appropriate action by management is punishment (3).  This employee’s behavior falls into the third category.  

Most laboratory professionals are uncomfortable handling these situations, and few of us have been taught how to handle them. I highly recommend the book, Lab Dynamics, Management Skills for Scientists (3), which has some very practical advice specifically aimed at personnel issues in labs.

In this situation, before attempting to correct the employee’s behavior, the lab directors should answer the following seven questions:

  1. Was there forewarning of the rule/expectation?
  2. Was the expectation reasonable?
  3. Was a thorough investigation done?
  4. Was the investigation fair and objective, including the chance to explain the actions and circumstances?
  5. Was there reasonable proof of a violation?
  6. Was the rule consistently and fairly applied?
  7. Is the proposed corrective action appropriate for the infraction?

The staff member described in this article has exhibited at-risk behavior and has not stopped the behavior despite frequent coaching. Assuming that management has clearly spelled out the expectations for the procedure and that the employee understands that the procedure must be followed, then I would advise proceeding with disciplinary action.

Lab director getting a good night’s sleep on a soft pillow
after successfully addressing an unsafe situation in the lab.

But what if your management refuses to take action? Some managers may not act because they are afraid of the ramifications or they may not know how to respond. If your lab has a human resources department, then I would urge you to share your concerns, provide documentation, and ask your manager to seek help from human resources.

Other actions should be taken when the offending party is a scientist or physician. For reckless behavior on the part of these employees, lab directors should seek the counsel of the chief of the medical staff, the vice president of medical affairs, the department chairperson or, in severe cases, psychiatric colleagues.

In addition to asking the questions above, we also use tools recommended by VitalSmarts called Crucial Conversations (4). Examples of crucial conversations include: giving your boss feedback about his or her behavior; critiquing a colleague’s work; giving an unfavorable performance review; and telling management about an unsafe practice. 

Accountability in the Just Culture Model
Types of Errors and Proper Responses

Error Type



Inadvertent error in a normally automatic task

  • Most aliquotting errors
  • Most math errors
  • Most mislabeling errors
  • Most data entry errors
  • Most specimen routing errors


At-risk behavior

  • Most examples of shortcutting, for example:
  • Reviewing microscope slide for less time than stated in procedure
  • Batch labeling of specimens at nurse station, rather than labeling at bedside

Coach and then monitor

Reckless behavior

  • Pouring specimen down sink and falsifying results
  • Performing lab services (phlebotomy, processing, testing, reporting) while under the influence of drugs or alcohol
  • Any at-risk behavior that has been repeatedly coached


The bottom line is that we cannot accept unsafe behavior in the clinical lab. Some managers/directors may excuse behavior by pointing to an employee’s technical skills. Technical skills are necessary, but not sufficient, to classify an employee as competent. An employee who is technically superb but engages in unsafe conduct surely poses a risk to patients.

Everyone is responsible for safety in the lab, not just management. It is the duty of the employees to bring unsafe issues to the attention of management, and it is up to the directors and managers to take action. I call these situations “jump-out-of-your-chair” issues, because they are important, urgent, and need focused, immediate attention. I also call these “soft-pillow-issues”, because if I deal with them promptly and professionally, then I sleep well at night.

Remember: safety is not negotiable when it comes to a patient’s health. Our patients are expecting no less.


  • Marx D. “Patient Safety and the Just Culture: A Primer for Health Care Executives.” Trustees of Columbia University in the City of New York, 2001.
  • Marx D. “Patient Safety and the Just Culture.” Available online. Accessed June 5, 2009.
  • Cohen C and Cohen S. Lab Dynamics, Management Skills for Scientists. Cold Spring Harbor Laboratory Press. Cold Spring Harbor, New York, 2005.
  • Vital Smarts website. Accessed June 5, 2009.

Patient Safety Focus Editorial Board

Michael Astion, MD, PhD
Department of Laboratory Medicine
University of Washington, Seattle

Peggy A. Ahlin, BS, MT(ASCP)
ARUP Laboratories
Salt Lake City, Utah 
James S. Hernandez, MD, MS 
  Mayo Clinic Arizona
Scottsdale and Phoenix

Devery Howerton, PhD

Centers for Disease Control and Prevention
Atlanta, Ga.

Sponsored by ARUP Laboratories, Inc.