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1. Facts & Assumptions
a. Is diagnosis correct?
b. Is prognosis correct?
c. Is treatment plan correct?
d. Is your information adequate?
e. Incorrect assumptions?
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2. Actions & Process Issues
a. Was the treatment administered properly?
b. Was documentation done correctly?
c. Was procedure followed?
d. Were there other options?
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3. Attitudes & Biases
a. Is this patient being labeled?
b. Do you ‘like' this patient as a person?
c. How would you want to be treated in similar situations?
d. Are there other ways to view the issue?
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4. System & Safety issues
a. What are the organizational issues?
b. Does the system have an existing plan to cover these problems?
c. Was it followed?
d. Could there be systems solution?
e. How do the organizational issues help us understand the problem?
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