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  1. 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 U N C H E A L T H C A R E U N 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 U N C H E A L T H C … Reporting Platform Goal: To develop optimized interface for our event reporting software for event
  2. 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.
  3. 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,
  4. 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
  5. 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)) .
  6. 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.  
  7. 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.
  8. 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
  9. 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
  10. 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
  11. 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?      
  12. 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
  13. 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.
  14. 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.
  15. 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.
  16. 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
  17. 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
  18. 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.
  19. 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.
  20. 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

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