The Incident Decision Tree: Guidelines for action following patient safety incidents (The National Patient Safety Agency)

Summary

The National Patient Safety Agency developed the Incident Decision Tree to help NHS managers in the UK to determine a fair and consistent course of action toward staff involved in patient safety incidents.

Research shows that systems failures are the root cause of the majority of safety incidents. Despite this, when an adverse incident occurs, the most common response is to suspend the clinician(s) involved, pending investigation, in the belief that this serves the interests of patient safety.

The Incident Decision Tree supports the aim of creating an open culture, where employees feel able to report patient safety incidents without undue fear of the consequences. The tool comprises an algorithm with accompanying guidelines and poses a series of structured questions to help managers decide whether suspension is essential or whether alternatives might be feasible.