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1. Mod4-Event-Checklist (pdf file)
   pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module4/mod4-event-checklist.pdf
   April 01, 2016 - CANDOR Event Checklist Communication and Optimal Resolution Toolkit CANDOR Process Steps Event Report … Receipt of Report How report was received: ■ Hotline: Enter event report via the institution’s event … ■ Advise care providers on appropriate medical record documentation post event. … Event Review ■ Schedule in-person interviews of key staff. … ■ Enter all information in the hospital event reporting system.

2. Module 4: Event Reporting, Event Investigation and Analysis | Agency for Healthcare Research and Quality
   pbrn.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes4.html
   August 01, 2022 - of the event are imperative. … information on the event. … all the steps involved in event reporting, including; How the event was reported. … After initial reporting of the event, the CANDOR Response Team responds to the location of the event … Providing guidance on how to report an event, including requested patient information, where the event

3. System-Focused Event Investigation and Analysis Guide | Agency for Healthcare Research and Quality
   pbrn.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4.html
   August 01, 2022 - Principles of an Event Review In other safety critical industries, event reviews are highly routinized … The most effective event investigation and analyses are conducted as quickly as possible after the event … that led up to the event. … stakeholders to understand the event. … No reinvestigation of the event.

4. Module 6: Care for the Caregiver | Agency for Healthcare Research and Quality
   pbrn.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes6.html
   August 01, 2022 - (s) involved in the event. … The reliving of the event is also known as a "tripping" or "triggering" event and can occur when the … The event might produce feelings of internal inadequacy, either because the event occurred or because … the post-event period. … , not just the details of the event.

5. Notification of Adverse Event: Video | Agency for Healthcare Research and Quality
   pbrn.ahrq.gov/patient-safety/settings/hospital/candor/videos/notification.html
   August 01, 2022 - and Events Education & Training Resources Notification of Adverse Event … This video demonstrates an example of caregivers notifying the CANDOR team of an adverse event. … 2022 Page originally created April 2016 Internet Citation: Notification of Adverse Event

6. NPSD Dashboards | Agency for Healthcare Research and Quality
   pbrn.ahrq.gov/npsd/data/dashboard/index.html
   October 01, 2023 - reports and event-specific dashboards that describe in greater depth specific safety events such as … The dashboard charts detail event type, report type by event type, extent of harm by event type, event … originated, and stage of process where event originated by residual harm to the patient.   … originated, and stage of process where event originated by residual harm to the patient.     … or Other Substance events, including description of substance event, stage event originated, and type

7. Module 1: An Overview of the CANDOR Process | Agency for Healthcare Research and Quality
   pbrn.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes1.html
   August 01, 2022 - A CANDOR event is an event that involves unexpected patient harm. … cause of a harm event. … the event. … Say: More information on Event Identification and Reporting of a CANDOR event will be discussed in … Resolution of the event can only occur after Event Investigation and Analysis has been completed.

8. Grand Rounds Presentation | Agency for Healthcare Research and Quality
   pbrn.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.

9. Disclosure Checklist | Agency for Healthcare Research and Quality
   pbrn.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.  

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

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

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

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

14. The PSO Privacy Protection Center | Agency for Healthcare Research and Quality
    pbrn.ahrq.gov/cpi/about/otherwebsites/psoppc.ahrq.gov/index.html
    September 01, 2018 - The PSOPPC provides technical assistance to PSOs to ensure that patient safety event data is rendered … The Common Formats promote consistent event reporting by all providers and health care organizations … assistance services, such as— Educating PSOs on the format for submitting nonidentifiable patient safety event … Rendering PSO patient safety event data nonidentifiable. … software vendors interested in implementing common definitions and reporting formats for patient safety event

15. Medication or Other Substance Dashboard | Agency for Healthcare Research and Quality
    pbrn.ahrq.gov/npsd/data/dashboard/medication.html
    October 01, 2023 - type of incorrect dose, type of incorrect dose by residual harm to the patient, stage of process where event … originated, and stage of process where event originated by residual harm to the patient.

16. Using Simulation in TeamSTEPPS Training: Classroom Slides | Agency for Healthcare Research and Quality
    pbrn.ahrq.gov/teamstepps/simulation/simulationslides/simslides.html
    June 01, 2019 - Return to Top   Define Event Sets Event sets are the building blocks of a scenario Event sets … Each event set should not include more than one trigger event . … Event sets can be created by breaking a clinical procedure into chunks . … The event sets or behavior categories can be used to structure discussion. … Rule of thumb: Have a key event every 1 to 2 minutes of scenario time.

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

18. Event Investigation and Analysis Guide: Appendix F | Agency for Healthcare Research and Quality
    pbrn.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apf.html
    August 01, 2022 - Patient Safety News and Events Education & Training Resources Event … name), we would like you to participate in our upcoming solutions meeting related to (describe safety event … is essential to develop effective solutions to the contributing and causal factors found during our event … Page last reviewed August 2022 Page originally created April 2016 Internet Citation: Event

19. Event Investigation and Analysis Guide: Appendix E | Agency for Healthcare Research and Quality
    pbrn.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/ape.html
    August 01, 2022 - Patient Safety News and Events Education & Training Resources Event … As you may know, a patient care incident occurred on (insert date) involving (brief description of event … An in-depth review of the event is complete. … Page last reviewed August 2022 Page originally created April 2016 Internet Citation: Event

20. Event Investigation and Analysis Guide: Appendix C | Agency for Healthcare Research and Quality
    pbrn.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apc.html
    August 01, 2022 - Patient Safety News and Events Education & Training Resources Event … This format helps to utilize the information found in the investigation to understand why the event occurred … Page last reviewed August 2022 Page originally created April 2016 Internet Citation: Event