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Showing results for "event".

1. Mod4-Event-Checklist (pdf file)
   talkingquality.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
   talkingquality.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
   talkingquality.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
   talkingquality.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. NPSD Dashboards | Agency for Healthcare Research and Quality
   talkingquality.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

6. Module 1: An Overview of the CANDOR Process | Agency for Healthcare Research and Quality
   talkingquality.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.

7. Grand Rounds Presentation | Agency for Healthcare Research and Quality
   talkingquality.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.

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

9. Disclosure Checklist | Agency for Healthcare Research and Quality
   talkingquality.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. Module 7: Resolution | Agency for Healthcare Research and Quality
    talkingquality.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.

11. Event Investigation and Analysis Guide: Appendix D | Agency for Healthcare Research and Quality
    talkingquality.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. Communication and Optimal Resolution (CANDOR) | Agency for Healthcare Research and Quality
    talkingquality.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

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

14. Mod5-Disclosure-Checklist (pdf file)
    talkingquality.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.

15. Patient Safety Organizations: A Summary of 2014 Profiles (pdf file)
    talkingquality.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).

16. AHRQ Quality Indicators Prioritization Worksheet Example (pdf file)
    talkingquality.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

17. PowerPoint Presentation
    talkingquality.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.

18. Mod01-Grand-Rounds-Slides (pdf file)
    talkingquality.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.

19. The PSO Privacy Protection Center | Agency for Healthcare Research and Quality
    talkingquality.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

20. Development and Usability Testing of the Agency for Healthcare Research and Quality Common Formats to Capture Diagnostic Safety Events (pdf file)
    talkingquality.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