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Action Effectiveness

Experience has shown that actions have varying degrees of effectiveness in preventing the recurrence of an error. Potential effectiveness needs to be considered when developing an action plan. Department of Veterans Affairs, National Center for Patient Safety recommmends the following hierarchy of actions:

Weaker Actions

  • Training/re-training
  • Procedure changes
  • Warnings and labels
  • Double checks

Intermediate Actions

  • Staffing level/workload changes
  • Software modifications
  • Reduce or eliminate distractions
  • Checklist/cognitive aid
  • Eliminate look/sound alikes
  • Read back
  • Enhanced documentation/ communication
  • Redundancy

Stronger Actions

  • Simplify the process and remove unnecessary steps
  • Standardize equipment or process or care-maps
  • Forcing functions - engineering control
  • New device/ equipment
  • Architectural changes
  • Tangible involvement and action by leadership in support of patient safety