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.
