I Who: Who was/were the ameliorator/s (can code multiple, if needed) | 1: Patient/Patient-Related | Patient, family member, patient representative |
2: Clinician | Physician, physician’s assistant, nurse practitioner |
3: Nurse | RN, MA, LPN |
4: Office staff | Front office staff, billing, administration, or medical records |
5: Lab or lab personnel | Laboratory technician |
6: Pharmacy or pharmacist | Pharmacist, pharmacy technician |
7: Radiology/radiology tech | Radiologists, radiology technician |
8: Other | Any 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 times | Most 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 above | The action taken is exceptional and goes above and beyond what would normally expect (“Wow! I didn’t expect that”) |
C: Insufficient information | Use 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? | PRE | Amelioration took place before event process started (eg, system change to prevent a future error; corrected medical record to prevent future error) |
EARLY | Amelioration took place early in the event process (eg, MD noticed wrote wrong dose on Rx and corrected before patient left) |
MID | Amelioration took place in middle of process (eg, pharmacy noticed dose was wrong, clarified with clinic, then dispensed correctly) |
LATE | Amelioration took place late in event process (eg, patient noticed that dispense pills were different and clarified before taking) |
V. System change? | SYSTEM | Use 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 |