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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.
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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
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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.
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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.
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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
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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.
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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.
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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)) .
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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.
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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.
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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?
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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
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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.
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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.
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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).
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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
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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.
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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.
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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
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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