Description Discussion, clarification, elaboration
Failure modes,
risks, barriers
Supportive
materials, standards,
references,
guidelines,
best practices,
resources, links
47 Limited e.g., authority to review protected health
information
HIPAA Business
Associate Agreement
48 Legal custody of a person Custody rights may
not be valid or clear
Court order
49 Access to selected information e.g., epidemiological, statistical, financial,
HIPAA exceptions
50 Right to treat against patient’s
wishes
51 Patient impaired e.g., intoxicated May be variable
52 Transfer involuntary or against
patient/representative objection
e.g., 72-hour mental health hold Formal processes
53 Patient incapable of consent e.g., unconscious, infant, etc.
H TRANSPORT CARRIER
54 Ground ambulance Communications
55 Private vehicle Lack of equipment
56 Unknown
57 Wheelchair Access
58 Ambulatory Mobility
59 Attendant, accompanying person e.g., parent carries child into exam room Authority
I PLANNING & PREPARATION
60 Assessment Appropriateness of the transition; readiness
of the patient and all other parties;
readiness of the receiver.
Receiving location not
prepared
61 Communication Clinical information, instructions, plans and
other relevant data transmitted to all who
need to know.
Information payload
not sent or received
62 Verification Appropriate assent and agreement of the
parties; understanding of plans, instructions
and other necessities by the patient and/or
receiver(s).
Patient or caregiver
does not understand
instructions
63 Monitoring Oversight of the process; documentation;
adjustments to contingencies and
problems.
No backup plan for
unexpected events
J COMMUNICATION MEDIUM & MODE
64 Verbal report Human factors SBAR; “Read-Back”;
audio/video recording;
voice-recognition
65 Electronic communication within
secure system
Unstructured, semi-structured or transfer of
a fully structured record set
Technology
66 Text messaging
67 Video teleconference Includes remote monitoring, “patient
generated data,” tele-health, tele-medicine
