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Table 1 The 6 “What” questions for the analysis of substandard factors*

From: The implementation of unit-based perinatal mortality audit in perinatal cooperation units in the northern region of the Netherlands

What question Question and sub questions (underlying purpose of the question or response options)
1. what happened? (identified substandard factor to be analysed) Stating the identified substandard factor defined as the care management problem that involves care that deviates from safe limits of practice as laid down in guidelines etc and had the potential to lead, directly or indirectly, to an adverse outcome for the patient
  1a. which caregivers were involved Here all caregivers, including secretarial, paramedical and auxiliary staff involved in the occurrence of the substandard factor are listed.
2. what were the circumstances in which the ssf occurred? (description of the situation) Short description of the relevant circumstances in which the SSF occurred (e.g. salient clinical events, timeframe, weekend or workday, physical and mental state of the patient, local situation, workload of the care giver, etc)
3. what made the ssf occur? (analyses of underlying causes)
  Stating the underlying cause(s) for the occurrence of the SSF, categorized into 6 groups:
  - patient related (e.g. distress, seriousness of the condition),
  - task related (e.g. availability of protocols and laboratory facilities),
  - care giver related (e.g. motivation, attitude, skills),
  - team related (e.g. communication between care givers, availability of supervision)
  - work environment related (e.g. staffing mix, availability of supporting staff)
  - management related (safety culture, financial resources)
  3a. determination if the underlying causes are relevant only to the case under analysis or a structural problem in the organization
4. what is the relation between the ssf and death? (categorization of the relation)
  - none: there is no relation between the identified SSF and the outcome
  - unlikely: it is unlikely that different management would have made a difference to the outcome
  - possible: different management might have made a difference to the outcome
  - probable: different management would reasonably be expected to have made a difference to the outcome.
  - very probable: a clearly avoidable factor implying that the adverse outcome could have been prevented.
5. what are the conclusions? ( analysis of the answers 1-4) Gives a point by point list of underlying causes leading to the occurrence of the SSF. (e.g. inadequate supervision, failure of monitoring equipment)
6. what needs to be done to prevent the ssf from occurring again? (action points) Gives a point to point list of action points for the improvement of care. (e.g. make a skills and drills program (including a roster) for all relevant personnel)
  1. * Based on the work of Vincent and Young (Vincent 2003, Young 2001).