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Incident Decision Tree

Reference number
1078
Issue date01 February 2004
TypeToolkit

The Incident Decision Tree aims to help the NHS move away from attributing blame and instead find the cause when things go wrong. The goal is to promote fair and consistent staff treatment within and between healthcare organisations.


Research carried out in the NHS has shown that systems failures are often the root cause of safety incidents. However, the most common response to a serious patient safety incident is to suspend and then discipline the staff involved. This can be unfair to employees and divert management from identifying contributory systems failures. Suspending key employees can also diminish the quality of patient care provided.


The Incident Decision Tree can help managers and senior clinicians:

  • decide whether it is necessary to suspend staff from duty following a patient safety incident;
  • explore alternatives to suspension, such as temporary relocation or modification of  duties; and
  • consider other possible measures to be taken as the investigation progresses.

 

The Incident Decision Tree is a web-based tool and is simple to use. It complements the Root Cause Analysis toolkit and the two can be used in parallel.