A | Need to elucidate meaning of principal problem | This has been clarified by re-structuring the stage and giving examples |
| Add to co-morbidity list | The co-morbidity list has been modified |
| Include time of event | Space to record the time of the event is included |
B | Answers to the following will be subjective: | Agree—but approximate data are useful |
| • Additional bed days caused by AE | |
| • Degree of disability | |
| • Emotional trauma | |
C | May be difficult to determine: | Agree—but may be able to determine whether or not there was lack of input from experienced staff |
| • Person responsible at that period of care | |
| • Date and time of event | |
D | May be difficult to determine: | |
| • How management contributed to the AE and respects in which it was unsatisfactory | Agree—but experienced reviewers will be able to make “intelligent estimates” |
| • Quality of hand over | |
| • Person responsible at the time of AE and whether or not it was appropriate | |
| • Whether there were avoidable delays or inappropriate procedures | |
| • The cause of drug related injury | |
E | Impossible to relate the relative importance of contributory factors | It is important that reviewers are adequately trained and that they are aware of their own limitations |
| Difficult to determine reasons for failure to prevent AE | As the form is modular, stage E may be omitted. |
| Specialist reviewers would be needed | Specialists should be consulted on specific points |