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41. Event Investigation and Analysis Guide: Appendix A | Agency for Healthcare Research and Quality
    talkingquality.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apa.html
    August 01, 2022 - Patient Safety Resources by Setting Hospital Hospital Resources CANDOR Event … Patient Safety News and Events Education & Training Resources Event … Event Summary:   The wrong concentration of potassium (K+) was used in the compounding of TPN. … Page last reviewed August 2022 Page originally created April 2016 Internet Citation: Event

42. Nursing Home Workplace Safety Resource List (pdf file)
    talkingquality.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/nursing-home-workplace-safety-resources.pdf
    January 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 … /sentinel-event-alert-60-developing-a-reporting-culture-learning-from- close-calls-and-hazardous-condi … /sentinel-event-alert-newsletters/sentinel-event-alert-60-developing-a-reporting-culture-learning-from-close-calls-and-hazardous-condi

43. How Does the NPSD Work? | Agency for Healthcare Research and Quality
    talkingquality.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

44. Final Progress Report: APPLIED STRATEGIES FOR IMPROVING PATIENT SAFETY (ASIPS) (pdf file)
    talkingquality.ahrq.gov/sites/default/files/2024-02/pace-report.pdf
    January 01, 2024 - range of errors attributable to a wide range of root causes and resulting from a wide range of event … Ameliorating an event after an initial error requires an opportunity to catch the error by systems, … A final sample of 119 patient calls regarding a clinical concern was used to abstract event data for … We were able to code 88 event narratives that met our usual criteria for a reportable event using the … From these 88 events, we found that 62% involved a clinical event.

45. Case Scenarios: Handling Challenging Communications | Agency for Healthcare Research and Quality
    talkingquality.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/scenarios.html
    August 01, 2022 - Contents Scenario 1: Non-Clinical Situation, Group Project Scenario 2: Disclosure Immediately After Event … Scenario 3: Disclosure After Event Analysis Scenario 4: Disclosure After Event Analysis Scenario 1 … Return to Contents Scenario 2: Disclosure Immediately After Event Mary is a 39-year-old mother … Return to Contents Scenario 3: Disclosure After Event Analysis Adam, a 55 year-old male is admitted … Return to Contents Scenario 4: Disclosure After Event Analysis Alphonse, a 50 year-old CEO of a

46. Care for the Caregiver Program Implementation Guide | Agency for Healthcare Research and Quality
    talkingquality.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide6.html
    August 01, 2022 - that these tiers of support are provided to caregivers after they have in been involved in an adverse event … YES  NO       Adverse Event Investigation Process Is an adverse event policy in place? … Do you have an event investigation process clearly outlined? … available interventional support strategies for clinicians in the aftermath of an unanticipated clinical event … Providing supportive care following an unanticipated clinical event.

47. Module 8: Organizational Learning and Sustainability | Agency for Healthcare Research and Quality
    talkingquality.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes8.html
    August 01, 2022 - After the resolution of a CANDOR event, information is fed into an organization’s performance improvement … These may include a checklist to follow after an event. … Event Reporting, Investigation, and Analysis Team. Resolution Team. … Ask patients and family members to share their stories to put a human face on a harm event and engage … Think about a patient story involving a CANDOR event.

48. C1 Prioritization Matrix (xls file)
    talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c2_combo_prioritizationworksheetexample.xlsx
    July 01, 2016 - ) Barrier Assessment (indicate Yes or No) Q3/10-Q2/11 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

49. Gap Analysis Facilitator's Guide: Appendix B | Agency for Healthcare Research and Quality
    talkingquality.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/apb.html
    August 01, 2022 - Does the hospital routinely use its REAL data to identify patient safety event disparities and establish … Is an attempt made to disclose within the first 24 hours following an adverse event? … Do staff have the opportunity to participate in event investigations and process improvement initiatives … Has an organized process to assess behavior related to the event been established? … Is supportive care provided to the caregiver within 24 hours of the event?

50. Gap Analysis Facilitator's Guide: Appendix C | Agency for Healthcare Research and Quality
    talkingquality.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/apc.html
    August 01, 2022 - Does the hospital routinely use its patient REAL data to identify patient safety event disparities and … Is an attempt made to disclose within the first 24 hours following an adverse event?         … Do staff have the opportunity to participate in event investigations and process improvement initiatives … Has an organized process to assess behavior related to the event been established?         … Is supportive care provided to the caregiver within 24 hours of the event?        

51. How PSOs Help Health Care Organizations Improve Patient Safety Culture (pdf file)
    talkingquality.ahrq.gov/sites/default/files/wysiwyg/npsd/npsd-patient-safety-culture-brief.pdf
    September 01, 2016 - One way to drive improved culture is to develop the norm of routine safety event reporting. … that encourage and facilitate patient safety Program Brief Network of Patient Safety Databases event … Several PSOs provide members a confidential analysis of patient safety event data, and provide forums … PSOs encourage voluntary patient safety event reporting by offering technical assistance and the … a series of calls to walk their members through procedures for efficiently and safely submitting event

52. An Overview of the CANDOR Process
    talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module8/module8-organizational-learning-sustainability.pptx
    August 20, 2015 - After the resolution of a CANDOR event, information is fed into an organization’s performance improvement … These may include a checklist to follow after an event.   … Communication Team Event Reporting, Investigation, and Analysis Team Resolution Team Identify CANDOR … Ask patients and family members to share their stories to put a human face on a harm event and engage … Think about a patient story involving a CANDOR event.

53. Module 4: Teamwork and Communication: Facilitator Notes | Agency for Healthcare Research and Quality
    talkingquality.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module4/mod4-facguide.html
    March 01, 2017 - The Debrief meeting is ideally conducted with all team members that were involved in the event. … Caring for the resident's physical needs after an event is the first step a provider must take. … However, prompt, compassionate, and honest communication following an event is essential. … , the resident's response to the event, and the care provided as a result of the event. … about an adverse event should be compassionate and sensitive.

54. Hospital Survey on Patient Safety Culture Version 2.0 (pdf file)
    talkingquality.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/SOPS-Hospital-Survey-2.0-5-26-2021.pdf
    January 01, 2021 - Instructions This survey asks for your opinions about patient safety issues, medical error, and event … • A “patient safety event” is defined as any type of healthcare-related error, mistake, or incident … When an event is reported in this unit, it feels like the person is being written up, not the problem … In this unit, we are informed about changes that are made based on event reports ........... … Hospital management seems interested in patient safety only after an adverse event happens .......

55. Mod03-Gap-Analysis-Guide (pdf file)
    talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module3/mod03-gap-analysis-guide.pdf
    April 01, 2016 - Has an organized process to assess behavior related to the event been established? e. … Is supportive care provided to the caregiver within 24 hours of the event? f. … Is an attempt made to disclose within the first 24 hours following an adverse event? … Has an organized process to assess behavior related to the event been established? … Is supportive care provided to the caregiver within 24 hours of the event?

56. Federal Interagency Workgroup: Improving Diagnostic Safety and Quality in Healthcare (pdf file)
    talkingquality.ahrq.gov/sites/default/files/wysiwyg/topics/public-notes-meeting-summary-111921.pdf
    March 11, 2022 - Conference included sessions or posters on the following AHRQ-supported work: Common Formats for Event … Indian Health Service • Enhanced Adverse Event Reporting Capabilities: o Reporting of adverse events

57. Morningbriefing (doc file)
    talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/morningbriefing.doc
    August 07, 2012 - After receiving an update on the patients, proceed to Question II, unless there was an adverse event. … If an adverse event occurred, you should also use the Learn From Defects Form. II.

58. Recommendations from the Subcommittee to Inform the National Action Alliance to Advance Patient and Workforce Safety | Agency for Healthcare Research and Quality
    talkingquality.ahrq.gov/cpi/about/nac/naa-snac-recommendations.html
    February 01, 2024 - Safety plans will include provisions for patient access to submit safety concerns, inclusion in event … include: Increase in the percentage of claims identified in reporting systems within 48 hours of an event … Implementation of robust communication and resolution programs with reported event feedback provisions

59. AHRQ Quality and Safety Review System (QSRS) | Agency for Healthcare Research and Quality
    talkingquality.ahrq.gov/cpi/about/otherwebsites/qsrs.ahrq.gov/index.html
    March 01, 2021 - Features The QSRS: Offers an expanded array of adverse event measures. … standardized definitions and algorithms, consistent with those used by the AHRQ Common Formats for Event

60. Transitioning to the SOPS™ Hospital Survey Version 2.0: What’s Different and What To Expect, Part II: Appendixes (pdf file)
    talkingquality.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hsops2-pt2_transition_apx.pdf
    September 01, 2019 - (F3R) Hospital management seems interested in patient safety only after an adverse event happens. … (C3) We are given feedback about changes put into place based on event reports. … (G1) (No event reports, 1 to 2, 3 to 5, 6 to 10, 11 to 20, 21 event reports or more) 45% 44% 1% … (C3) We are given feedback about changes put into place based on event reports. … (G1) (No event reports, 1 to 2, 3 to 5, 6 to 10, 11 to 20, 21 event reports or more) 45% 44% 1%