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41. PowerPoint Presentation
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module7/module7-resolution-facilitator.pptx
    August 24, 2015 - Resolution addresses the needs and concerns of patients after an adverse event. … Determine fair and reasonable compensation for the patient/family after an adverse event. … Potential future injuries that may result from the adverse event. … of time to report the adverse event. … The severity level of adverse events reported. Length of time it takes to disclose the event.

42. AHRQ’s Safety Program for Nursing Homes: On-Time Prevention | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/overview.html
    November 01, 2017 - Generally, a nursing home works on one adverse event at a time. … event occurs. … Reports that identify residents who have had an adverse event and that show risk information, treatment … Implementation Materials Two worksheets are provided for each adverse event. … event.

43. Disclosure Checklist | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/checklist5.html
    August 01, 2022 - is identified, advise the patient and/or family that an adverse event may have occurred.   … Identify the adverse event early in the disclosure.   … Explain what is known about why the adverse event occurred; do not speculate.   … Tell the patient whether the adverse event was preventable, if known.   … Be honest EXPLAIN the facts about the adverse event without the patient having to do a lot of probing

44. Outpatient Benzodiazepine Prescribing, Adverse Events, and Costs (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/French.pdf
    April 27, 2004 - Outpatient Benzodiazepine Prescribing, Adverse Events, and Costs 185 Outpatient Benzodiazepine Prescribing … , Adverse Events, and Costs Dustin D. … Benzodiazepine Prescribing and Adverse Events 193 Table 5. … Potential adverse outcomes of psychotropic and narcotic drug use in Canadian seniors. … Fall-contributing adverse effects of the most frequently prescribed drugs.

45. Final Progress Report: Incident Reporting Practices in Nursing Homes (pdf file)
    www.ahrq.gov/sites/default/files/2025-02/castle-report.pdf
    January 01, 2025 - This study found numerous barriers and few facilitators to adverse event reporting. … This study found numerous barriers and few facilitators to adverse event reporting. … Only 15% of responding facilities have a system in place for staff to enter adverse event data using … State Policies Associated with Adverse Event Reporting in Nursing Homes. … event 2.19 (0.06) Individual 5 Difficulty in proving that an adverse event actually occurred 2.09

46. Adverse Events | Agency for Healthcare Research and Quality
    www.ahrq.gov/research/findings/evidence-based-reports/adverse-events.html
    April 01, 2018 - Adverse Events Structured Abstract Full Title: Empirical Evaluation of the Association Between … Methodological Shortcomings and Estimates of Adverse Events Objective: Accurate harms data are necessary … A quality-rating instrument with four of the five criteria predicted adverse events (5.7 percent in studies … Evaluation of the latter two data sets was limited by small numbers of trials and low rates of evaluated adverse … Report Empirical Evaluation of the Association Between Methodological Shortcomings and Estimates of Adverse

47. CommonSpirit Health Expands CANDOR Toolkit Across Entire Health System | Agency for Healthcare Research and Quality
    www.ahrq.gov/news/newsroom/case-studies/202104.html
    October 01, 2021 - CommonSpirit Health clinicians have communicated promptly and candidly with patients about an adverse … event or potential adverse event, and officials estimate 85 patients were spared the additional harm … “It’s all about how to communicate an adverse event or a potential adverse event promptly and candidly … In regularly scheduled “Patient Safety Roundtables,” CommonSpirit Health clinical leaders review adverse … “CANDOR is absolutely the right approach for all involved in an adverse event,” Pelletreau said.

48. Module 6: Care for the Caregiver | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes6.html
    August 01, 2022 - the best care possible to patients, health care providers are sometimes faced with the aftermath of adverse … It is estimated that one in seven patients is affected by adverse events, and that as many as half of … all clinicians will be involved in a serious adverse event at least once during their career. … errors are adverse events. … Therefore, it is important to recognize the distinction between medical errors and adverse events, as

49. Grand Rounds Presentation | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/grand-rounds.html
    August 01, 2022 - event. 1.5% experienced harm that contributed to their death. 44% of adverse events were preventable … Slide 7 Say: Open and honest communication after an adverse event is not easy and does require … Slide 19 Say: The CANDOR process involves a thorough investigation of the adverse event … analysis of an adverse event.  … Resolution should lead to a settlement of issues related to the adverse event,but doesn’t always lead

50. The Relationship Between Hospital Workload and Patient Safety (pdf file)
    www.ahrq.gov/sites/default/files/2024-09/weissman-rothschild-report.pdf
    January 01, 2024 - event identification and incorporated rule sets with criteria to define adverse event. … Table E2: Adverse events explicitly specified for identification during chart review Adverse event … drug event Other adverse event not specified above A significant difficulty with the assessment of … events and the time of adverse event occurrence. … Demonstration of the Computerized Adverse Event Detection Tool (CADET).

51. Final Progress Report: Enhancing the Detection and Management of Adverse Drug Events in the Nursing Home (pdf file)
    www.ahrq.gov/sites/default/files/2024-02/handler-report.pdf
    January 01, 2024 - Sample Adverse Drug Event Alert and provided structured recommendations to intervention physicians about … Sample Adverse Drug Event Alert with SBAR Message to the Physician Setting Four UPMC‐owned NHs were … Potential Adverse Drug Event Alerts and Alert Distribution During the study, 1350 potential ADE alerts … Utility of an adverse drug event trigger tool in Veterans Affairs nursing facilities.  … The use of Health Information Technology for Adverse Event Reporting in Nursing Homes: Barriers and 

52. Final Progress Report: Conference on Medical Error Communication and Dispute Resolution (pdf file)
    www.ahrq.gov/sites/default/files/2024-07/liebman-hyman-report.pdf
    January 01, 2024 - event or a medical error. … Presenters explored the benefits and risks of apology and disclosure after an adverse event or medical … event, patient-physician communication. … event or medical error. … event or a medical error.

53. PowerPoint Presentation
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/module5-response-disclosure-notes.pptx
    August 21, 2015 - Disclosure communication following an adverse event should include answers to the following questions … How will the organization prevent the adverse event from happening to another patient in the future? … It is important that the clinicians and the health care organization apologize for the adverse event, … Apology–say you are sorry for the adverse event in a sincere manner early in the conversation. … identify actions needed to prevent the adverse event from happening to another patient in the future

54. Prioritization Worksheet (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/c1_pdi_prioritizationworksheetinstructions.pdf
    June 02, 2025 - and thus have accrued more costs even prior to the adverse event. … Therefore, choose a group that did not experience the adverse event that is as comparable as possible … both costs and risk of the adverse event (e.g., concurrent cancer diagnosis). … Ideally, if your data permit, consider only costs that occur after the adverse event occurred. … Compare the total costs of having an adverse event (Column G, Total Cost) with the anticipated cost

55. Implementation Guide for the CANDOR Process | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/impguide.html
    August 01, 2022 - event. … and analyzed, and a plan is developed to prevent the adverse event from reoccurring. … event. … event. … event (see Adverse Event (Reasonable Care) and Adverse Event (Unreasonable Care)) .

56. Mod5-Disclosure-Checklist (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/mod5-disclosure-checklist.pdf
    April 01, 2016 - is identified, advise the patient and/or family that an adverse event may have occurred … ■ Identify the adverse event early in the disclosure. … ■ Explain what is known about why the adverse event occurred; do not speculate. … ■ Tell the patient whether the adverse event was preventable, if known. … Apologize ■ Say you are sorry for the adverse event in a sincere manner early in the conversation.

57. Patient and Family Engagement | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/cusp/modules/patient-family-engagement/sl-pat-fam.html
    September 01, 2013 - Introduction to Adverse Events Slide 23. Immediate Response to an Adverse Event 4 Slide 24. … Next Steps in Responding to an Adverse Event 5 Slide 25. … How to Communicate About an Adverse Event 6 Slide 26. … Introduction to Adverse Events Adverse event: An injury to a patient caused by medical intervention … Next Steps in Responding to an Adverse Event 5 Investigation.

58. Prioritization Worksheet (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c1_combo_prioritizationworksheetinstructions.pdf
    June 02, 2025 - • Appropriate comparator: When trying to identify the cost attributable to an adverse event captured … and thus have accrued more costs even prior to the adverse event. … Therefore, choose a group that did not experience the adverse event that is as comparable as possible … Ideally, if your data permit, you would consider only costs that occur after the adverse event occurred … Compare the total costs of having an adverse event (Column G, Total Cost) with the anticipated cost

59. Mod01-Grand-Rounds-Slides (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/grandrounds/mod01-grand-rounds-slides.pdf
    April 01, 2016 - ■ 44% of adverse events were preventable. … analysis of an adverse event. … It explains that after an adverse event, regardless of whether it is due to human or system error, all … Resolution should lead to a settlement of issues related to the adverse event, but doesn’t always lead … Slide 38 Say: The concept of accountability relates to what patients want, following an adverse event

60. Patient and Family Engagement for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/pf-engagement-fac-guide.html
    July 01, 2023 - Discuss how to communicate an adverse event to patients and family members. … Engaging after an adverse event. Engaging in planning and design. … Immediately after an adverse event, care providers: Provide care. … a number of emotions when an adverse event occurs. … Rarely does an adverse event occur as a result of intent.