Description Discussion, clarification, elaboration
Failure modes,
risks, barriers
Supportive
materials, standards,
references,
guidelines,
best practices,
resources, links
32 Instructions for patient and
caregivers
Verbal or written instructions, patient
education (including educational/teaching
needs/goals).
Language barriers,
literacy
33 Patient generated stipulations Care parameters and goals; advance
directives (e.g., Living Will, Durable Power
of Attorney), verbal, written or inferred
wishes or chosen representatives.
Not asked; not acted
upon
Five Wishes, DPOA,
informed consent
documents, etc.
34 Contact information Self, family, providers, caregivers,
pharmacy, etc.
Not current.
E OTHER (PHYSICAL) PAYLOAD
35 Medical supplies,
pharmaceuticals, blood products
Things attached to the patient; for
consumption during transport or upon
arrival; for contingencies.
Misplaced, lost,
damaged
36 Documents, media Not the content but the physical media. Misplaced, lost,
damaged
37 Assistive devices, equipment e.g., dentures, corrective lenses, splint,
crutches
Misplaced, lost,
damaged
38 Biological specimen e.g., blood, urine, organs Misplaced, lost,
damaged
39 Personal property e.g., wallet, purse, keys, jewelry Misplaced, lost,
damaged
F SCOPE
40 Transfer of full responsibility for
an indefinite period
Initiator expects to resume care Tasks/plans not
communicated, goals
not understood,
Receiver not prepared,
equipped, competent,
appropriate, available
Task List or Care Plan
41 Transfer of full responsibility for a
defined period
e.g., sign out to on-call provider;
anesthesiologist manages resuscitation
parameters in the OR
Incomplete sign-
out, ambiguity,
misunderstanding
42 Joint responsibility – referral Receiver becomes principally responsible,
but Initiator retains some active
responsibility
43 Joint responsibility – consultation Receiver has limited responsibility; may not
have direct patient contact
44 Joint responsibility –
collaboration, shared care
e.g., surgical team, ICU team, specialist
management of defined aspects of care
45 Permanent discharge from care Transfer to another provider Emergency
G AUTHORITY
46 Normal The authority that normally belongs to a
healthcare provider; informed, voluntary
patient consent.
Nobody in charge;
multiple people in
charge, defects in
informed consent.
Care coordination
