1. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ The Incident Decision Tree…

2. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Culpability Individuals can be:- Accountable for error Responsible for error...but need not always also be: - Culpable for error Peter Pronovost

3. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ “The single greatest impediment to error prevention is that we punish people for making mistakes” Dr Lucian Leape, Harvard School of Public Health

4. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ The Incident decision tree An electronic interactive tool designed for NHS managers dealing with staff who have been involved in an incident Supports managers considering action and alternatives to suspension Encourages fair and consistent treatment across the NHS Aims to avoid Hindsight bias and Outcome bias Developed by NPSA, NCAA, NHS Confederation, Royal Colleges and Trade Unions

5. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Concerns about suspensions Longstanding concerns about number and duration of staff suspensions in NHS. Seen as by-product of ‘blame culture’. Concerns borne out by NAO report 2003. - available on their website www.nao.gov.ukwww.nao.gov.uk

6. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ “The Management of suspensions of clinical staff in NHS hospitals and ambulance Trusts in England ” NAO Report November 2003 April 01 - July 02, over 1,000 clinical staff suspended Average length of suspension = 47 weeks for Doctors =19 weeks for other staff No returning to work = 40% doctors / 44% others Cost per suspension = £188,000 on average per doctors = £ 21,400 for other staff Cost to NHS = £11 million per year

7. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Anecdotal findings from studies Authority to suspend widely devolved. Nurses more likely to be suspended than other staff groups. The less experienced the manager, the more likely they are to suspend. Most incidents involve protocol violation. Widespread confusion re: ‘formal suspension’ and sending home in immediate aftermath.

8. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ How the IDT works Structured questions move through 4 ‘tests’ The Deliberate Harm Test The Physical and Mental Health Test The Foresight Test The Substitution Test

9. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/

10. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/

11. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ The IDT can be used: By any manager dealing with staff involved in a patient safety incident For any employee, whatever their professional group The IDT should be : Step by step and electronically Separately for each person being considered www.npsa.nhs.uk The IDT must be used : Revisited and updated as info. is gathered to assist decision making

12. Content from National Patient Safety Agency material http://www.nationalarchives.gov.uk/doc/open-government-licence/version/2/ Key Points – IDT Aim is to encourage:- Fair, objective, consist approach to error Consideration of systemic and organisational issues Consideration of alternatives to suspension. Open reporting of patient safety incidents.