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21. Event Investigation and Analysis Guide: Appendix C | Agency for Healthcare Research and Quality
    pcmh.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

22. Communication and Optimal Resolution (CANDOR) Toolkit | Agency for Healthcare Research and Quality
    pcmh.ahrq.gov/patient-safety/settings/hospital/candor/modules.html
    August 01, 2022 - Organizational Buy-in and Support Module 3: Preparing for Implementation: Gap Analysis Module 4: Event … Reporting, Event Investigation and Analysis Analysis Module 5: Response and Disclosure Module 6: … Generally, the CANDOR process begins with identification of an event that involves harm. … This activates initiation of coordinated post-event processes, as depicted below and described in the … Investigate and analyze an adverse event to learn from it and prevent future adverse events.

23. Mod5-Disclosure-Checklist (pdf file)
    pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/mod5-disclosure-checklist.pdf
    April 01, 2016 - ■ 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. … event. … ■ Consider ways to involve patients in post-event learning.

24. Patient Safety Organizations: A Summary of 2014 Profiles (pdf file)
    pcmh.ahrq.gov/sites/default/files/wysiwyg/npsd/npsd-portfolios-summary-profile-2014.pdf
    January 01, 2014 - not in all event categories, and 13 PSOs in all event categories). … PSOs that collect patient safety event reports for single event types did so only for anesthesia, surgery … about 6 percent of patient safety event reports submitted by providers to PSOs. … Figure 3 shows the distribution of PSOs by type of event reports collected. Figure 3. … analyze the event with an RCA to identify the causal factor(s).

25. AHRQ Quality Indicators Prioritization Worksheet Example (pdf file)
    pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c2_combo_prioritizationworksheetexample.pdf
    June 29, 2016 - Anticipated average cost for one case with this event The total annual cost of this event to … Anticipated average cost for one case with this event The total annual cost of this event to … Anticipated average cost for one case with this event The total annual cost of this event to … Anticipated average cost for one case with this event The total annual cost of this event to … Anticipated average cost for one case with this event The total annual cost of this event to

26. PowerPoint Presentation
    pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module1/grand-rounds-presentation-slides.pptx
    January 01, 2014 - 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. … place after event analysis is completed.

27. Mod01-Grand-Rounds-Slides (pdf file)
    pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/grandrounds/mod01-grand-rounds-slides.pdf
    April 01, 2016 - 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.

28. Development and Usability Testing of the Agency for Healthcare Research and Quality Common Formats to Capture Diagnostic Safety Events (pdf file)
    pcmh.ahrq.gov/sites/default/files/wysiwyg/topics/development-and-usability-testing-common-formats.pdf
    January 01, 2022 - Agency for Healthcare Research and Quality (AHRQ) began the de- velopment of the Common Formats for Event … Results: Estimated completion time was 30 to 90 minutes per event. … The CFER-DS also offers a definition of a diagnostic safety event using concepts pro- posed in 2 prior … Participants were asked to complete the CFER-DS to simulate event reporting for 5 cases of diagnostic … DISCUSSION Standards for diagnostic safety event reporting are necessary to advance national-level

29. Identify Defects Through Sensemaking | Agency for Healthcare Research and Quality
    pcmh.ahrq.gov/hai/cusp/modules/identify/identify.html
    December 01, 2012 - The purpose is to reduce the ambiguity about the event/issue—literally to make sense of it. … Each person brings his or her experience of that event/issue to the discussion. … Antecedent Event Root Causes Root Cause Classification Codes Recovery Return to Contents … Providers must also correct the factors that contribute to an event. … The attributes of medical event-reporting systems: Experience with a prototype medical event-reporting

30. Survey on Patient Safety (facility version) (doc file)
    pcmh.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.doc
    November 15, 2019 - Safety Instructions This survey asks for your opinions about patient safety issues, medical error, and event … to answer a question, or if a question does not apply to you, you may leave your answer blank. · An “event … When an event is reported, it feels like the person is being written up, not the problem (1 (2 (3 … No event reports ( d. 6 to 10 event reports ( b. 1 to 2 event reports ( e. 11 to 20 event reports … ( c. 3 to 5 event reports ( f. 21 event reports or more SECTION H: Background Information This

31. AHRQ Quality and Safety Review System (QSRS) | Agency for Healthcare Research and Quality
    pcmh.ahrq.gov/patient-safety/quality-measures/qsrs/index.html
    September 01, 2022 - Overall, the QSRS will generate adverse event rates and trend performance over time. … The QSRS also: Offers an expanded array of adverse event measures, including ones related to opioid … standardized definitions and algorithms, consistent with those used by the AHRQ Common Formats for Event … This approach ensures that an event identified at one institution is the same as one identified elsewhere

32. Prioritization Worksheet (pdf file)
    pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c1_combo_prioritizationworksheetinstructions.pdf
    June 05, 2016 - In column E, “Volume of Cases at Risk,” indicate the annual volume of each PSI, IQI, and/or PDI event … Column F, “Cost of Single Event,” indicates the average cost to your organization of one event. … We have not included cost estimates for a single event directly in the worksheet, as you may want to … Has your organization recently experienced negative press regarding an event? … What would this look like in the community if you had an event in your organization?

33. Medication or Other Substance Supplement Dashboard | Agency for Healthcare Research and Quality
    pcmh.ahrq.gov/npsd/data/dashboard/medication-supplement.html
    September 01, 2023 - includes information organized by medication events at a glance, including description of substance event … , stage event originated, and type of substance involved for incidents, near misses, and unsafe conditions

34. Facilitator's Notes | Agency for Healthcare Research and Quality
    pcmh.ahrq.gov/teamstepps/simulation/traininggd.html
    July 01, 2016 - The Simulation Module for Assessment of Resident Targeted Event Responses (SMARTER) approach is an event-based … All event sets consist of a trigger—the condition under which the event becomes fully activated or the … Each event set should include only one trigger event to avoid introducing too many variables and making … Explain that each slide can be chunked into two event sets, with one trigger for each event set. … Event set with trigger and distracters.

35. Improving Workplace Safety in Hospitals: A Resource List for Users of the AHRQ Workplace Safety Supplemental Item Set (pdf file)
    pcmh.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/workplace-safety-resources.pdf
    May 01, 2023 - /resources/patient-safety-topics/sentinel-event/sentinel- event-alert-newsletters/sentinel-event-alert … /sentinel-event-alert-newsletters/sentinel-event-alert-59-physical-and-verbal-violence-against-health-care-workers … / https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/sentinel-event-alert-newsletters … /resources/patient-safety-topics/sentinel-event/sentinel-event-alert-newsletters/sentinel-event-alert … / https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/sentinel-event-alert-newsletters

36. Event Investigation and Analysis Guide: Appendix B | Agency for Healthcare Research and Quality
    pcmh.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apb.html
    August 01, 2022 - Patient Safety News and Events Education & Training Resources Event … Investigation and Analysis Guide: Appendix B Detailed Review Timeline Event Type: Individuals … Timeline of Event: March 12, 2014 (0900) RN#1 received report from ED on patient Mrs. … Page last reviewed August 2022 Page originally created April 2016 Internet Citation: Event

37. Federal Interagency Workgroup: Improving Diagnostic Safety and Quality in Healthcare (pdf file)
    pcmh.ahrq.gov/sites/default/files/wysiwyg/topics/dagnostic-safety-workgroupmeeting-notes-july2022.pdf
    November 03, 2022 - • Common Format for Event Reporting – Diagnostic Safety o AHRQ released the Common Formats for Event … The Event Description, Users’ Guide and Glossary, and Form are all available here. … IHS • Enhanced Adverse Event Reporting Capabilities o IHS Safety Tracking and Response (I-STAR) is deployed … improvement project to better identify and facilitate the reporting of diagnostic errors through voluntary event

38. Patient and Family Engagement | Agency for Healthcare Research and Quality
    pcmh.ahrq.gov/hai/cusp/modules/patient-family-engagement/notes.html
    September 01, 2013 - Immediate Response to an Adverse Event 4 Slide 24. … How to Communicate About an Adverse Event 6 Slide 26. … What if an Adverse Event Occurs on the Unit? … event, and the care provided as a result of the event … of emotions when an adverse event occurs.

39. How Does the NPSD Work? | Agency for Healthcare Research and Quality
    pcmh.ahrq.gov/npsd/how-does-npsd-work/index.html
    February 01, 2024 - Patient Safety Organization Privacy Protection Center (PSOPPC) using the AHRQ Common Formats for Event … The AHRQ Common Formats for Event Reporting can be used to report patient safety concerns, a term that … Presently, data must comply with AHRQ's Common Formats for Event Reporting (CFER) in order to be accepted

40. Hospital SOPS Translation Information | Agency for Healthcare Research and Quality
    pcmh.ahrq.gov/sops/international/hospital/translators.html
    October 01, 2014 - Hospital management seems interested in patient safety only after an adverse event happens. … When an event is reported, it feels like the person is being written up, not the problem. … The term "rating" can be used instead of "grade." ) Number of Events Reported (No event reports, … 1 to 2 event reports, 3 to 5 event reports, 6 to 10 event reports, 11 to 20 event reports, 21 event reports … In the past 12 months, how many event reports have you filled out and submitted?