Event Investigation and Analysis Guide: Appendix H

Hierarchy of Solutions

Do solutions meet the following criteria:

  • Address the root cause/contributing factor.
  • Are specific and concrete.
  • Can be understood and implemented by a reader unfamiliar with the situation.
  • Will be tested or simulated prior to full implementation (when feasible).
  • Based on consultation with process owners.

Recommended Hierarchy of actions—adapted from the Department of Veterans Affairs National Center for Patient Safety):

Stronger actions
  • Architectural/physical plant changes.
  • New device with usability testing before purchasing.
  • Engineering control or interlock (forcing functions).
  • Simplify the process and remove unnecessary steps.
  • Standardize equipment or process or caremaps.
  • Tangible involvement and action by leadership in support of patient safety.
Intermediate Actions
  • Increase in staffing/decrease in workload.
  • Software enhancements/modifications.
  • Eliminate/reduce distractions (sterile medical environment).
  • Checklist/cognitive aid.
  • Eliminate look- and sound-alike medications.
  • Read back.
  • Enhanced documentation/communication.
  • Redundancy.
 Weaker Actions
  • Double checks.
  • Warnings and labels.
  • New procedure/memorandum/policy.
  • Training.
  • Additional study/analysis.

 

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Page last reviewed February 2017
Page originally created April 2016
Internet Citation: Event Investigation and Analysis Guide: Appendix H. Content last reviewed February 2017. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module4-guide-aph.html