Classifying Unsafe Health and Care Behaviors in the Context of Just Culture: A Comparative Video-Based Vignette Study

Background: Just Culture requires organizations to distinguish human mistakes from unsafe behavior while maintaining transparency, accountability and trust. However, little is known about how different stakeholders interpret these boundaries in realistic healthcare situations. This study aimed to explore how unsafe healthcare behaviors are classified by professionals and community and public-opinion stakeholders within the framework of Just Culture. Methods: This structured judgment study used standardized video vignettes across primary care, hospital, and nursing home settings. A purposive and convenience sample of 449 healthcare professionals, managers, and community/public representatives classified behaviors as honest error, at-risk behavior, or reckless behavior and provided written justifications. Concordance with a prespecified study-defined reference classification was examined using mixed-effects logistic regression. Results: Across 2976 classification opportunities, 2610 were analyzable within the three predefined categories. At-risk behavior was most frequent (40.5%), followed by honest error (33.5%) and reckless behavior (25.9%). Exact concordance with the prespecified reference classification was 48.4% and was highest for reckless behavior (67.4%). Participants' justifications for their classification choices centered on intention, contextual pressure, foreseeability, omitted safety barriers, professional duty, and relational expectations. Conclusions: Participants generally distinguished human fallibility from the omission of available safeguards, but many behaviors were located in an intermediate zone of at-risk conduct rather than clear error or recklessness. The observed variability in interpreting error, risk, and responsibility, particularly around at-risk behavior, may be relevant to the implementation of Just Culture.