Safety-culture tool is launched in the NHS

National Patient Safety Agency (NPSA) has launched a decision-making tool to
reduce unnecessary suspensions and support a safety culture within the NHS.

‘Incident Decision Tree’ is a tool to help NHS managers determine the best
course of action for dealing with a member of staff following a patient safety

November 2003, the National Audit Office (NAO) released a report called The
Management of Suspensions of Clinical Staff. It found that between April 2001
and July 2002, more than 1,000 full-time clinical staff were excluded at an
estimated cost of £29m to the NHS.

NAO identified occasions where clinicians were excluded despite evidence of
systematic failures rather than individual shortcomings, and highlighted the
need to improve the management of suspensions.

Incident Decision Tree is an electronic, interactive tool designed for NHS
managers dealing with staff involved in an incident. Based on a model developed
for the aviation industry by Professor James Reason, a world-leading academic
in the field of understanding error, it prompts the user with a series of
questions to help them take a systematic, transparent and fair approach to

joint chief executive, Susan Williams, said: "All too often in the past,
the immediate response to an error in the NHS has been to blame the member of
staff involved and to ignore the underlying causes. The evidence tells us that
often when things go wrong the causes can be traced back to systems. An
automatic decision to blame and suspend staff makes it more likely that errors
will be covered up and that the right lessons will not be learned.

primary concern is the safety of the patients, and it is essential that staff
are suspended when serious concerns are raised and that poor clinical
performance is tackled. However, it is in the interests of all concerned that
alternatives to suspension are carefully considered, and this tool is designed
to support managers through this decision-making process and promote a
consistent approach."

Incident Decision Tree will help NHS staff to:

decide whether staff should be suspended from duty

explore alternatives to suspension, such as temporarily relocating staff or
changing their duties; and

consider other actions as the investigation progresses.

By Quentin Reade

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