The Decision Framework: Patient Safety First

Every SJT question can be approached with a single, consistent framework: a priority hierarchy that determines what matters most when values and obligations compete. This lesson establishes that framework and shows you how to apply it to any scenario you encounter.

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The Universal Priority Hierarchy

When multiple considerations compete in an SJT scenario, apply this hierarchy from top to bottom:

Priority	Principle	What it means
1	Patient safety	If a patient could be harmed, address this first — always
2	Raising concerns	If you see something unsafe or unethical, your duty is to raise it
3	Following protocol and professional standards	Adhere to guidelines, procedures, and professional expectations
4	Personal comfort and convenience	Your own feelings, relationships, and preferences come last

This hierarchy is the single most useful tool for SJT. When you are unsure about a question, ask: "Which priority level is this scenario testing?" and choose the answer that aligns with the highest applicable level.

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Priority 1: Patient Safety

What "Patient Safety" Encompasses

Threat	Example
Immediate physical harm	A medication error about to be administered
Delayed harm	A colleague consistently underperforming, leading to cumulative risk
Psychological harm	A patient being humiliated or distressed by staff behaviour
Systemic risk	A faulty process or equipment that affects multiple patients
Omission of care	A deteriorating patient who has not been reviewed

How Patient Safety Overrides Other Priorities

Scenario	What you might want to do	What patient safety requires
A senior colleague makes a prescribing error	Stay quiet to avoid confrontation	Speak up immediately
A friend and colleague seems impaired by alcohol	Protect your friend's reputation	Report to the senior clinician on duty
A nurse is cutting corners on hand hygiene	Maintain a good working relationship	Address the issue directly or escalate
You are running late for teaching	Leave the ward	Ensure the patient in front of you is safe before you go
A patient's relative is verbally abusive	Walk away to protect yourself	Ensure the patient is safe; seek security if needed; do not abandon the patient

SJT Scenario

Scenario: You are a medical student on your last day of a surgical placement. During a routine procedure, you notice that the surgical count (checking all instruments are accounted for before closing) has not been performed. The registrar is in a hurry to finish because the next patient is waiting.

Action	Rating	Why
Politely ask the registrar whether the surgical count has been completed	Very appropriate	Patient safety is the top priority; leaving an instrument inside a patient could be catastrophic
Say nothing because it is your last day and you do not want to create problems	Very inappropriate	Prioritises personal comfort over patient safety
Mention it to the scrub nurse and ask if they can remind the registrar	Appropriate, but not ideal	Addresses the issue indirectly; ideally, raise it yourself as well
Wait until after the procedure and mention it to the consultant	Inappropriate, but not awful	Too late — the risk needs to be addressed before the patient is closed

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Priority 2: Raising Concerns

The Duty to Raise Concerns

When you observe something unsafe, unethical, or unprofessional, you have a duty to raise it. This duty applies regardless of:

Factor that does NOT excuse inaction
Your position in the hierarchy ("I am just a student")
Your relationship with the person involved ("They are my friend")
The likely consequences for you ("They might give me a bad reference")
Your uncertainty ("I might be wrong")
The effort involved ("It is too much hassle")

The Escalation Decision Tree

When you identify a concern, decide:

Step 1: Is the risk immediate?

• Yes → Act now. Speak to the most senior person available. Do not wait
• No → Move to Step 2

Step 2: Can the issue be resolved through direct conversation?

• Yes → Speak to the person involved privately and professionally
• No (the person is too senior, the issue is too serious, or the direct approach has failed) → Move to Step 3

Step 3: Escalate to your supervisor or the appropriate authority

• Clinical supervisor, ward manager, consultant, or organisational channels as appropriate

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Priority 3: Following Protocol and Professional Standards

When Protocol Matters