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Adverse event analysis

Initial Analysis

Incident decision tree

The Incident Decision Tree (National Patient Safety Agency, UK) is designed to help managers decide initial action to take with staff involved in patient safety incidents. The tool is based on a flowchart which guides the use through a series of structured questions about the individual’s action, motives and behviour at the time of the incident. The responses to these questions lead to suggestions for appropriate management action. The Incident Decision Tree has been simplified and translated into Arabic by APSA for educational and local adaptation purposes.

Incident decision tree booklet - Arabic

Incident decision tree booklet - English

Incident decision tree flow chart - Arabic

Incident decision tree flow chart - English

System Analysis

London Protocol

The purpose of the protocol is to ensure a comprehensive and thoughtful investigation and analysis of an incident, going beyond the more usual identification of fault and blame. A structured process of reflection is generally more successful than either casual brainstorming or the suspiciously quick assessments of ‘experts’. The approach described does not supplant clinical expertise or deny the importance of the reflections of individual clinicians on an incident. Rather the aim is to utilise clinical experience and expertise to the fullest extent.

London Protocol - English

London Protocol - Arabic