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21. Implementation of an Event Reporting and Learning System Leads to Improvements in Patient Safety Culture at UNC Medical Center-Fenton-Wilhelm-Amos (pdf file)
    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

22. Grand Rounds Presentation | Agency for Healthcare Research and Quality
    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.

23. Event Investigation and Analysis Guide: Appendix I | Agency for Healthcare Research and Quality
    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,

24. Exhibit 9. Top five minimal cut sets for the basic case | Agency for Healthcare Research and Quality
    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

25. Implementation Guide for the CANDOR Process | Agency for Healthcare Research and Quality
    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)) .

26. Disclosure Checklist | Agency for Healthcare Research and Quality
    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.  

27. Module 7: Resolution | Agency for Healthcare Research and Quality
    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.

28. Mapping a Large Patient Safety Database to the 2005 Patient Safety Event Taxonomy (pdf file)
    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

29. Exhibit 11. Importance measures on events in rank order of criticality | Agency for Healthcare Research and Quality
    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

30. Exhibit 13. Probability of intervention reducing risk of surgical site infection (SSI) by multiple concurrent interventions at various reductions of noncompliance rates (25, 5 | Agency for Healthcare Research and Quality
    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

31. Event Investigation and Analysis Guide: Appendix D | Agency for Healthcare Research and Quality
    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?      

32. Ventilator-Associated Event Data Collection Tool | Agency for Healthcare Research and Quality
    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

33. Network of Patient Safety Databases Chartbook, 2023 (pdf file)
    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.

34. Mixed Methods Analysis of Medical Error Event Reports: A Report from the ASIPS Collaborative (pdf file)
    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.

35. Implementation of a Data-based Medical Event Reporting System in the U.S. Department of Defense (pdf file)
    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.

36. CLABSI and CAUTI Learning Tools | Agency for Healthcare Research and Quality
    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

37. Communication and Optimal Resolution (CANDOR) | Agency for Healthcare Research and Quality
    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

38. An Overview of the CANDOR Process
    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.

39. Module 5: Response and Disclosure | Agency for Healthcare Research and Quality
    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.

40. Exhibit 10. Probability variations used in the sensitivity analyses | Agency for Healthcare Research and Quality
    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