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21. Event Investigation and Analysis Guide: Appendix E | Agency for Healthcare Research and Quality
    talkingquality.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/ape.html
    August 01, 2022 - Patient Safety Resources by Setting Hospital Hospital Resources CANDOR Event … 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

22. Event Investigation and Analysis Guide: Appendix F | Agency for Healthcare Research and Quality
    talkingquality.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apf.html
    August 01, 2022 - Patient Safety Resources by Setting Hospital Hospital Resources CANDOR Event … 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

23. Survey on Patient Safety (facility version) (doc file)
    talkingquality.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

24. Improving Workplace Safety in Hospitals: A Resource List for Users of the AHRQ Workplace Safety Supplemental Item Set (pdf file)
    talkingquality.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

25. Prioritization Worksheet (pdf file)
    talkingquality.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?

26. Event Investigation and Analysis Guide: Appendix C | Agency for Healthcare Research and Quality
    talkingquality.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apc.html
    August 01, 2022 - Patient Safety Resources by Setting Hospital Hospital Resources CANDOR Event … 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

27. Federal Interagency Workgroup: Improving Diagnostic Safety and Quality in Healthcare (pdf file)
    talkingquality.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

28. Communication and Optimal Resolution (CANDOR) Toolkit | Agency for Healthcare Research and Quality
    talkingquality.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.

29. Sample Disaster Preparedness Letter to Families (doc file)
    talkingquality.ahrq.gov/sites/default/files/wysiwyg/nursing-home/resources/letter-emergency-contact.docx
    May 12, 2022 - health, safety, and dignity of your loved one and are committed to protecting our residents in the event … we can contact during an emergency to share our plans for sheltering in place or evacuation in the event … We would discuss this option further with you while we prepare for such an event. … Please complete the information below for our records so we know how best to proceed in the event of

30. Event Investigation and Analysis Guide: Appendix B | Agency for Healthcare Research and Quality
    talkingquality.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apb.html
    August 01, 2022 - Patient Safety Resources by Setting Hospital Hospital Resources CANDOR Event … 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

31. Hospital Survey on Patient Safety (doc file)
    talkingquality.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospitalscanform.doc
    June 09, 2016 - Instructions This survey asks for your opinions about patient safety issues, medical error, and event … · An “event” is defined as any type of error, mistake, incident, accident, or deviation, regardless … 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

32. Hospital Survey on Patient Safety (pdf file)
    talkingquality.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospitalscanform.pdf
    December 22, 2017 - • An “event” is defined as any type of error, mistake, incident, accident, or deviation, regardless … When an event is reported, it feels like the person is being written up, not the problem ......... … We are given feedback about changes put into place based on event reports ......................... … 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 information

33. Patient and Family Engagement | Agency for Healthcare Research and Quality
    talkingquality.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.

34. Hospital SOPS Translation Information | Agency for Healthcare Research and Quality
    talkingquality.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?

35. Medication or Other Substance Dashboard | Agency for Healthcare Research and Quality
    talkingquality.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.

36. Major Study Shows Significant Drop in In-Hospital Adverse Event Rates Pre-COVID | Agency for Healthcare Research and Quality
    talkingquality.ahrq.gov/news/newsletters/e-newsletter/822.html
    July 01, 2022 - Newsletter AHRQ News Now Major Study Shows Significant Drop in In-Hospital Adverse Event … Now Events Major Study Shows Significant Drop in In-Hospital Adverse Event … Today's Headlines: Major Study Shows Significant Drop in In-Hospital Adverse Event Rates Pre-COVID … Major Study Shows Significant Drop in In-Hospital Adverse Event Rates Pre-COVID The rates of in-hospital … July 2022 Internet Citation: Major Study Shows Significant Drop in In-Hospital Adverse Event

37. C1 Prioritization Worksheet (xls file)
    talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c1_combo_prioritizationworksheet.xlsx
    July 01, 2016 - disagree/low) Barrier Assessment (indicate Yes or No) Volume of Cases at Risk Cost of Single Event … G H I J K L M N O P Q R List of PSIs/IQIs/PDIs Own Rate National Comparator Annual volume of this event … Anticipated average cost for one case with this event The total annual cost of this event to our organization … Anticipated cost to investigate/ implement new process is less than annual cost of event Anticipated … with established organizational goals and priorities • Regulatory • Value-based purchasing • Sentinel event

38. Module 3: Preparing for Implementation: Gap Analysis | Agency for Healthcare Research and Quality
    talkingquality.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/notes.html
    August 01, 2022 - Define a CANDOR event. Develop a measurement strategy. … Event Reporting, Investigation, and Analysis Team—responsible for reviewing the organization’s current … Slide 6 Say: A CANDOR event is defined as an event that involves unexpected harm (physical, … As the culture begins to change, the organization can start to expand the definition of a CANDOR event … and Event Investigation and Analysis.

39. Event Investigation and Analysis Guide: Appendix G | Agency for Healthcare Research and Quality
    talkingquality.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apg.html
    August 01, 2022 - Patient Safety Resources by Setting Hospital Hospital Resources CANDOR Event … Patient Safety News and Events Education & Training Resources Event … Page last reviewed August 2022 Page originally created April 2016 Internet Citation: Event

40. AHRQ Quality and Safety Review System (QSRS) | Agency for Healthcare Research and Quality
    talkingquality.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