Adverse Events Decision Pathway for Nurse Leaders & Administrators

Following principles of the systems approach and just culture, the Adverse Events Decision Pathway (AEDP) suggests a complete investigation of the adverse event, as well as a review of the nurse's behavioral choices which may have contributed to any adverse event. The AEDP reflects a balance between justice and fairness on the one hand and the need to learn from a mistake and disciplinary action when appropriate on the other hand.

In partnership with the facility quality team, an internal investigation on the adverse event occurrence should be conducted. With the data from the investigation, use the AEDP starting with the first question on the pathway and progressing to other questions based on affirmative or negative answers leading to a determination of the nurse's behavioral choice: intent to harm, reckless behavior or termination/suspension/resignation, at risk behavior or human error. Categorization of behavioral choice leads to suggestions including action plans for the nurse, reporting to the BON or law enforcement.

State boards of nursing (BONs) may also have specific requirements for special or mandatory reporting to the BON. Information regarding reporting requirements is found in the individual state Nurse Practice Act and Rules and Regulations, Specific report format and process can be found on the state BON website.

Behavioral Choices by the Nurse

The AEDP focuses its evaluation of the cause of the practice error or unprofessional conduct by considering the following.

Whether or not the nurse’s behavioral choices included any of the following:

  • deliberate harm
  • concealment of the error
  • substantial or unjustifiable risk – significant possibility that an adverse outcome may occur

Whether or not the nurse’s history includes:

  • other similar or serious errors
  • received remediation or counseling for a similar error

Whether or not any significant mitigating factors existed:

  • Mitigating factors would include extenuating, explanatory or justifying fact, situation or circumstance

Whether or not a reasonably prudent nurse could have done the same in similar circumstances:

  • A reasonably prudent nurse is a nurse who uses good judgment in providing care according to accepted standards

Influence of the System

In the AEDP, a system is defined as an organization’s operational methods, processes or infrastructure/environment. For example, the evaluation of the system could include whether there were deficits in the facility’s policies and/or procedures, other providers in the health care system were partially or solely responsible, or whether there were any other institutional factors that contributed to the error.