Just Culture — Decision Guide for Managers
Before anyone is blamed: the substitution test and the four questions that separate a system failure from an individual one
What it is
A one-page decision guide adapted from the NHS Just Culture Guide: deliberate harm test, health test, foresight (substitution) test, and mitigating circumstances — with the action that follows each answer.
Where to use it
Every manager, before any conversation with a staff member about an incident; in the HR and incident procedures. Evidence for: Governance — safety culture; Code of Conduct. Evidence for: Governance — safety culture; Code of Conduct. Evidence for: Governance — safety culture; Code of Conduct. Evidence for: Governance — safety culture; Code of Conduct. Evidence for: Governance — safety culture; Code of Conduct. Evidence for: Governance — safety culture; Code of Conduct. Evidence for: Governance — safety culture; Code of Conduct.
Translate and adapt
English master edition. Georgian and other translations are added as they are clinically reviewed. Any facility may translate, add its logo and adapt wording to local practice — keeping the ASF block, the source attribution and the licence line on the sheet. Clinical thresholds and drug doses must be confirmed against national protocols before use.
The same code is printed on the tool itself. Scan it in any facility to reach this page.
Patient Safety Incident Report
Incident Severity and Response Matrix
Root Cause Analysis — Worksheet
Safety Learning Bulletin — Monthly, One Page
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