Table 1

 Initial code list for analysis of event report text

DomainCodeDefinition
I Who: Who was/were the ameliorator/s (can code multiple, if needed)1: Patient/Patient-RelatedPatient, family member, patient representative
2: ClinicianPhysician, physician’s assistant, nurse practitioner
3: NurseRN, MA, LPN
4: Office staffFront office staff, billing, administration, or medical records
5: Lab or lab personnelLaboratory technician
6: Pharmacy or pharmacistPharmacist, pharmacy technician
7: Radiology/radiology techRadiologists, radiology technician
8: OtherAny other person not in the above categories
II What: (a) Was the amelioration expected, typical action; OR unexpected above and beyond. If patient was the ameliorator, no code needed.A: Most people, most timesMost people, most of the time would take this action; it would be expected for most people to do this under the event circumstances.
B: Over and aboveThe action taken is exceptional and goes above and beyond what would normally expect (“Wow! I didn’t expect that”)
C: Insufficient informationUse to indicate there seems to be insufficient information to code the event in this domain.
III What: (b) What exactly did the ameliorator do (eg, phone call, double-check, asked questions, etc)[open code or in vivo code]Descriptive codes to get a sense of types of things people do when they ameliorate (eg, phone call, asked extra questions, double-checked, actually followed protocol)
IV When: At what point in the process (ie, the entire loop for an event procedure or activity) did the amelioration occur?PREAmelioration took place before event process started (eg, system change to prevent a future error; corrected medical record to prevent future error)
EARLYAmelioration took place early in the event process (eg, MD noticed wrote wrong dose on Rx and corrected before patient left)
MIDAmelioration took place in middle of process (eg, pharmacy noticed dose was wrong, clarified with clinic, then dispensed correctly)
LATEAmelioration took place late in event process (eg, patient noticed that dispense pills were different and clarified before taking)
V. System change?SYSTEMUse to indicate a change made to system or protocol or practice (ie, implemented an office-wide change), either as a part of the amelioration or as a result of the event