The Incident Decision Tree: Guidelines for Action Following Patient Safety Incidents

http://www.ahrq.gov/downloads/pub/advances/vol4/Meadows.pdf

Summary:

An Incident Decision Tree (IDT) was formulated to address patient safety issues arising in the United Kingdom. The IDT was developed by the National Health Service (NHS) in response to the alarming number of suspensions incurred by medical staff when patient safety issues arose.

The IDT provides human resource decision makers with a tool for determining the correct line of action when dealing with personnel in the wake of a patient safety issue. The overwhelming course of action before the IDT's implementation was a suspension for the health practitioner. The IDT proposes several different options for managers to consider after working their way through the tree. Applying the IDT allows the manager to implement fair and consistent actions resulting from patient safety mishaps.

The decision maker must think through the system and organization variables in the management of error from the prompts displayed throughout the tree. There are four consecutive trees a manager must consider about the situation. The first is the deliberate harm test (harm is intended), the incapacity test (the practitioner is sick, on medication, or has substance abuse problems), the foresight test (uncertain about protocal, protocal is unstated or poorly adhered to), and the substitution test (an equal would have acted differently). Each subsequent test is applied after the previous test was deemed inappropriate.

The pilot use of the IDT resulted in fewer suspensions for health care practitioners. Also, this lessened to a certain extent the "blame culture" associated with health care providers about self-reporting patient safety issues. Managers focused more on the "what" of the situation, rather than the "who."

A certain weakness was noted when human resource decision makers used the paper version of the IDT. Some decision makers chose suspension as the course of action and then worked backwards through the tree to justify their course of action.