AUTOMATIC TRANSCRIPT
Incident decision tree following james reason
1. 387 The Incident Decision Tree: Guidelines for Action Following Patient Safety Incidents Sandra Meadows, Karen Baker, Jeremy Butler Abstract The National Patient Safety Agency has developed the Incident Decision Tree to help National Health Service (NHS) managers in the United Kingdom 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. The approach does not seek to diminish health care professionals’ individual accountability, but encourages key decisionmakers to consider systems and organizational issues in the management of error. Initial findings show the Incident Decision Tree to be robust and adaptable for use in a range of health care environments and across all professional groups. It is hoped that applying the tool throughout the NHS will encourage open reporting of actual and prevented patient safety incidents and promote a uniformly fair and consistent approach toward the staff involved. Introduction The National Patient Safety Agency (NPSA) was established in 2001 to facilitate and coordinate changes in culture and practice across the United Kingdom (U.K.) National Health Service (NHS), with the aim of promoting and improving patient safety.1, 2 Its key roles include: • Raising awareness of patient safety issues. • Improving understanding of the causes of adverse incidents and near incidents. • Creating a National Reporting and Learning System (NRLS) both to capture incidents affecting patient safety and to learn from them. • Developing practical tools and guidance to assist in the above. The NHS was established in 1948 to provide free health care to all citizens at the point of need. It is the largest organization in Europe, employing more than 1 million staff.3 These comprise:
2. Advances in Patient Safety: Vol. 4 388 • 700,000 professional clinical staff • 350,000 clinical support staff • 200,000 infrastructure support staff • 90,000 family doctor (general practitioner) practice staff (excluding nurses) Patient safety solutions in the NHS must therefore be sufficiently robust and adaptable to address the diversity of need and function of the local organizations operating within its framework. Why the tool has been developed More than a million people are treated safely and successfully in the NHS every day. However, health care delivery is an increasingly complex and high-risk activity. Despite the dedication and professionalism of staff, things can and do go wrong. Research shows that approximately 10 percent of patients admitted to U.K. hospitals suffer some kind of patient safety incident.1 Most of these incidents are minor and transient, but a very small number prove severe and fatal. It is estimated that up to half of all incidents may be preventable.1 The way in which such incidents are handled is of critical importance to the future safety of patients and to the effectiveness of the NHS. Integral to an improvement in patient safety is the need to analyze and learn from adverse incidents. Historically, however, patient safety incidents have been infrequently reported, particularly where patients have suffered no lasting harm. When submitted, reports have been discussed locally only and not used as learning tools to prevent similar occurrences elsewhere. One of the primary reasons for low reporting levels has been the predominance of a “blame culture,” where the likelihood of disciplinary action by the employer and/or regulatory body, coupled with the growing threat of litigation, has conspired to keep health care professionals from speaking out. David Marx, an international consultant in human error management, explains how anxiety inhibits most U.S. health care workers from reporting incidents: “Few people are willing to come forward and admit to an error when they face the full force of their corporate disciplinary policy, a regulatory enforcement scheme, or our onerous tort liability system.”4 Marx further asserts, “Today, most corporate disciplinary systems literally prohibit human error. That is, mere human error, when coupled with harm to a patient, will raise the specter of social condemnation and disciplinary action.”4