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1. Module 4: Event Reporting, Event Investigation and Analysis | Agency for Healthcare Research and Quality
   teamstepps.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

2. System-Focused Event Investigation and Analysis Guide | Agency for Healthcare Research and Quality
   teamstepps.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.

3. Module 6: Care for the Caregiver | Agency for Healthcare Research and Quality
   teamstepps.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.

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

5. NPSD Dashboards | Agency for Healthcare Research and Quality
   teamstepps.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. Implementation Guide for the CANDOR Process | Agency for Healthcare Research and Quality
   teamstepps.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)) .

7. Module 7: Resolution | Agency for Healthcare Research and Quality
   teamstepps.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.

8. Event Investigation and Analysis Guide: Appendix D | Agency for Healthcare Research and Quality
   teamstepps.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?      

9. Communication and Optimal Resolution (CANDOR) | Agency for Healthcare Research and Quality
   teamstepps.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

10. Mod5-Disclosure-Checklist (pdf file)
    teamstepps.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.

11. AHRQ Quality Indicators Prioritization Worksheet Example (pdf file)
    teamstepps.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

12. The PSO Privacy Protection Center | Agency for Healthcare Research and Quality
    teamstepps.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

13. Event Investigation and Analysis Guide: Appendix F | Agency for Healthcare Research and Quality
    teamstepps.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

14. Survey on Patient Safety (facility version) (doc file)
    teamstepps.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

15. Prioritization Worksheet (pdf file)
    teamstepps.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?

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

17. Event Investigation and Analysis Guide: Appendix C | Agency for Healthcare Research and Quality
    teamstepps.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

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

19. Communication and Optimal Resolution (CANDOR) Toolkit | Agency for Healthcare Research and Quality
    teamstepps.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.

20. Sample Disaster Preparedness Letter to Families (doc file)
    teamstepps.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