Substitution Test – It’s Just Culture

The Substitution Test

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When they have done the same thing?

The protocol or standard was followed

Sometimes, the procedures and protocols were followed and something still goes wrong. This can be considered a "known complication." Treat this as you would any system failure.

A system failure prevented following the procedure

Perhaps the procedure is not available, workable, or intelligible. In this case, a reasonable peer acting sensibly would also not have been able to follow protocol.

Choice was the lesser of two evils

Lesser of two evils

Sometimes we encounter $h*%ty situations, and the right choice (the lesser of two evils) can still result in harm. This is a "known complication" of the circumstances converging.

Pervasive cultural drift

This is not typical cultural drift - this is rampant, pervasive cultural drift throughout the profession. No one follows this protocol. Example: professional chefs foregoing recipes when preparing food.

This was a function of inexperience

Function of inexperience

A critical function of the substitution test is to assess the choice against peers with the same experience. If a reasonable peer would have lacked the same foresight, it is a function of inexperience, not the fault of this person.