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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/4-unc-webcast-fenton-wilhelm-amos.pdf
August 15, 2019 - Implementation of an Event Reporting and Learning System Leads to Improvements in Patient Safety Culture … 32
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N
C H E A L T H C A R E
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C H E A L T H C A R E
Perceived barriers to event … reporting software
• Double event report submissions by 100% within three years
• Increase SOPS scores … in Feedback, Nonpunitive response and Event
Reporting by 2021
35
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C H E A L T H C … Reporting Platform
Goal: To develop optimized interface for our event reporting software for event
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/candor/grand-rounds.html
August 01, 2022 - actually compounded the injury from the event itself. … An event report is completed, which will trigger analysis of the event. … The Investigation: to determine how the event occurred, and how to mitigate that event or even prevent … analysis of an adverse event. … Host event analysis training using tools from CANDOR.
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/api.html
August 01, 2022 - Causal factor: the suspected or confirmed factors that caused the adverse event. … Often, multiple factors must intersect for an adverse event to reach the patient. … The purpose of the event review and analysis is to help clarify the causal factors. … Event review: the overall process of assessing an adverse safety event to determine contributing factors … In-depth event review: the data-gathering phase of an event review, involving conducting interviews,
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ce.effectivehealthcare.ahrq.gov/research/findings/final-reports/stpra/stpraexh9.html
April 01, 2018 - Event 142 (0.3)
Staff not well-trained in infection control
Event 450 (0.293)
Obese, … Event 182 (0.2)
Fail to administer indicated antibiotics
Event 543 (0.0325)
SSI risk for … during home care
Event 433 (0.05)
Patient has organism at postoperative visit
Event 543 … Event 30 (0.125)
Fail to prepare skin appropriately
Event 543 (0.0325)
SSI risk for obese … Event 450 (0.293)
Obese, but not diabetic, patient (30Event 642 (0.2)
Fail
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/candor/impguide.html
August 01, 2022 - A CANDOR event is defined as an event that involves unexpected harm (physical, emotional, or financial … A CANDOR event is defined as an event that involves unexpected harm (physical, emotional, or financial … After the event is identified as a CANDOR event, CANDOR System Activation occurs and triggers the start … reporting system, event investigation, and event analysis. … (see Adverse Event (Reasonable Care) and Adverse Event (Unreasonable Care)) .
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/candor/modules/checklist5.html
August 01, 2022 - 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.
… Explain your role in the event to the patient/family; avoid blaming others or "the system" for the event … Consider ways to involve patients in post-event learning.
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes7.html
August 01, 2022 - However, litigation is not always a patient’s or family’s first instinct after an adverse event, so it … Resolution addresses the needs and concerns of patients after an adverse event. … Patients want to know what will be done to prevent the event from happening again. … Some organizations choose to involve patients/families in some manner in the event analysis process. … Potential future injuries that may result from the adverse event.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Clarke_8.pdf
January 25, 2008 - These event types drive the collection of information
germane to a specific event. … as a near-miss or
“serious event”; the clinical event type according to the PA-PSRS taxonomy used in … PA-PSRS;
the procedure involved; how the event was discovered; the disposition of the event; and the … 75.5
Date of admission 37.9
Type (near-miss or serious event) 37.6
How was event discovered 37.6 … Event type (modified UHC taxonomy) 37.6
Disposition of event 37.6
Procedure error: Procedure 30.0
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ce.effectivehealthcare.ahrq.gov/research/findings/final-reports/stpra/stpraexh11.html
April 01, 2018 - Birnbaum
Fussell–
Vesely
Event 642 Fail to protect patient effectively (failure related to … , but not diabetic, patient (30 < BMI < 40)
0.3147
0.0047
0.3147
Event 543 SSI risk for obese … 0.0070
0.2003
Event 456 Patient is a smoker and has COPD
0.1649
0.0135
0.1649
Event 659 … 0.1457
Event 138 Fail to remove watch/jewelry/fake nails
0.1291
0.0038
0.1291
Event 644 … 0.0995
0.0012
0.0995
Event 241 Tourniquet time >60min
0.0956
0.0051
0.0956
Event 660 Patient
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ce.effectivehealthcare.ahrq.gov/research/findings/final-reports/stpra/stpraexh13.html
April 01, 2018 - References for Fault Tree Model Probability Estimates
References
Event
Event 30 … Gate 239
Event 142
Event 659
Event 138
25% reduction in noncompliance
Event 30 Fail to prepare … 142 Staff not well-trained in infection control
–
–
0.0041
0.0039
0.0039
Event 659 Glove … puncture
–
–
–
0.0042
0.0041
Event 138 Fail to remove watch/jewelry/fake nails
–
– … 142 Staff not well-trained in infection control
–
–
0.0038
0.0035
0.0035
Event 659 Glove
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apd.html
August 01, 2022 - COMMUNICATION
Was there a handoff involved in the event? What happened during the handoff? … CARE PROCESS
Did this event take place during a procedure, test, or skilled task? … CULTURE
Was this event communicated to the patient and family? … CULTURE
Was this event placed in the patient safety event reporting system?
… CULTURE
Was this event shared throughout the organization?
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ce.effectivehealthcare.ahrq.gov/hai/tools/mvp/modules/vae/tool.html
January 01, 2017 - Program
Tools
Mechanically Ventilated Patients Toolkit
Ventilator-Associated Event … Telemedicine
Universal ICU Decolonization Protocol
Ventilator-Associated Event … ______ Unit __________
Use this tool to track your progress in reducing ventilator-associated event … 2017
Page originally created January 2017
Internet Citation: Ventilator-Associated Event
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-chartbook-2023.pdf
January 01, 2023 - event types. … OF EVENT OR UNSAFE
CONDITION by EVENT TYPE. … to the event?” … event? … (EVENT ID); and the REPORT TYPE, category of event (EVENT TYPE), and INITIAL
REPORT DATE.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Harris.pdf
June 30, 2004 - event) or a “0” (not assigned to
that event). … In addition to qualitatively coding event narratives, we developed flow charts
of event activities for … questions about
the event. … event Fixed choice (Yes/No) + optional brief narrative
Was a system involved in the event? … • Describe the event.
• Lead to or affect the downstream outcome of the event.
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Davis.pdf
February 12, 2004 - a
“sentinel event” was used. … was a near miss or an actual event. … Each actual event is categorized with a
SAC score. … If there
are no subcategories for an event, the number given to the event or the event
description … is usually a condensed
version of the event and gives no causal factors related to the event.
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ce.effectivehealthcare.ahrq.gov/hai/tools/clabsi-cauti-icu/implement/learning-tools.html
April 01, 2022 - They both support a thorough review of the event to identify and address the defect of the infection. … The event reporting tools have a comprehensive list of questions specific to CLABSI and CAUTI. … CLABSI Event Report Tool (Word, 273.6 KB)
CAUTI Event Report Tool (Word, 269.7 KB)
CLABSI Learn
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/candor/index.html
August 01, 2022 - Notes ( PowerPoint , 836 KB)
Tool: Gap Analysis Facilitator's Guide ( PDF , 440 KB)
Module 4: Event … Reporting, Event Investigation and Analysis
Event Reporting, Event Investigation, and Facilitator … Notes ( PowerPoint , 1 MB)
Tool: CANDOR Event Checklist ( PDF , 200 KB)
Tool: System-Focused Event … Care
Video; Resolution Planning
Video: Conversation with Family
Adverse Event—Unreasonable Care … Video: Notification of Adverse Event
Video: Planning for Meetings with Family
Video: Disclosure
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ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module4/module4-event-reporting-investigation-analysis.pptx
September 10, 2015 - Reporting,
Event Investigation and Analysis
Module 4 of the CANDOR Toolkit covers the Event Reporting … Identify the key components of an effective event analysis.
2
CANDOR Event Reporting,
Investigation, … of the event are imperative.
… information on the event. … in event reporting, including;
How the event was reported.
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ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/notes.html
August 01, 2022 - and of the impact of the event on their care. … What are the implications of the event for the patient's health?
Why did the event happen? … the system" for the event. … Can I see a copy of the event analysis? … It is rarely helpful to share all event analysis findings.
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ce.effectivehealthcare.ahrq.gov/research/findings/final-reports/stpra/stpraexh10.html
April 01, 2018 - References for Fault Tree Model Probability Estimates
References
Event
Probability … Event 28 Patient colonized with MRSA
0.10 to 0.30
Event 29 Non-MRSA patient
0.90 to 0.70
Event … 0.50 to 0.90
Event 182 Fail to administer indicated antibiotics (staff)
0.20 to 0.40
Event 203 … 0.15 to 0.50
Event 405 Patient understands, but does not follow, postoperative directions
0.10 … to 0.25
Event 622 Alcoholic patient fails to comply with instruction for not drinking prior to the