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1. Mod4-Event-Checklist (pdf file)
   www.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. CAUTI Event Reporting Tool (doc file)
   www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/clabsi-event-reporting.docx
   April 01, 2022 - CAUTI Event Reporting Tool CLABSI Event Report Tool: Data for Event Analysis This event report template … In addition, the data gathered from multiple CLABSI event investigations can and should be aggregated … Lastly, do not wait too far out to complete the event report tool as it may be difficult to fill in the … AHRQ Safety Program for Intensive Care Units: Preventing CLABSI and CAUTI CLABSI Event Report

3. CLABSI Event Reporting Tool (doc file)
   www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/cauti-event-reporting.docx
   April 01, 2022 - CLABSI Event Reporting Tool CAUTI Event Report Tool: Data for Event Analysis This event report tool … In addition, the data gathered from multiple CAUTI event investigations can and should be aggregated … Lastly, do not wait too far out to complete the event report tool as it may be difficult to fill in the … Preventing CLABSI and CAUTI AHRQ Safety Program for ICUs: Preventing CLABSI and CAUTI CAUTI Event

4. Operational-Adjustments-Event-Summary (pdf file)
   www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/operational-adjustments-event-summary.pdf
   July 02, 2020 - Operational Adjustments while Resuming In-Person Cardiac Rehabilitation Programs July 2, 2020 Event … curtailed due to the pandemic • Format: A moderated panel discussion with five peers and the 120 event … LPN, CCCC Comanche County Memorial Health in Lawton, OK Slides and a recording of the event … Overall Event Themes: • Capacity Reduction: In general, cardiac rehabilitation programs have reduced … Patient Reflections (from Event Chat) Consider forming or using your patient advisory board to get

5. CAUTI Event Reporting Tool (doc file)
   www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/clabsi-event-reporting_revised.docx
   April 01, 2022 - CAUTI Event Reporting Tool CLABSI Event Report Tool: Data for Event Analysis This event report template … In addition, the data gathered from multiple CLABSI event investigations can and should be aggregated … Lastly, do not wait too far out to complete the event report tool as it may be difficult to fill in the … AHRQ Safety Program for Intensive Care Units: Preventing CLABSI and CAUTI CLABSI Event Report

6. CLABSI Event Reporting Tool (doc file)
   www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/cauti-event-reporting-revised.docx
   April 01, 2022 - CLABSI Event Reporting Tool CAUTI Event Report Tool: Data for Event Analysis This event report tool … In addition, the data gathered from multiple CAUTI event investigations can and should be aggregated … Lastly, do not wait too far out to complete the event report tool as it may be difficult to fill in the … Preventing CLABSI and CAUTI AHRQ Safety Program for ICUs: Preventing CLABSI and CAUTI CAUTI Event

7. Module 4: Event Reporting, Event Investigation and Analysis | Agency for Healthcare Research and Quality
   www.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes4.html
   August 01, 2022 - Module 4: Event Reporting, Event Investigation and Analysis AHRQ Communication and Optimal Resolution … 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

8. Innovations-Improve-Cr-Event-Summary (pdf file)
   www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/innovations-improve-cr-event-summary.pdf
   May 20, 2021 - EVENT SUMMARY LEARNING COMMUNITY AFFINITY GROUP | SUMMARY AT-AT-GLANCE | 1 AFFINITY GROUP DETAILS … Format • A moderated panel discussion with four panelists, with additional input from the 131 event … EVENT SUMMARY LEARNING COMMUNITY AFFINITY GROUP | SUMMARY AT-AT-GLANCE | 2 OVERALL EVENT THEMES … Additional Details Event slides and a recording of the event provide additional details that complement … The event slides and recording are available online at: TAKEheart.ahrq.gov

9. Mod4-System-Focused-Event-Guide (pdf file)
   www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module4/mod4-system-focused-event-guide.pdf
   April 01, 2016 - The sole objective of the event investigation and analysis of an adverse event or near miss is the … Principles of an Event Review In other safety critical industries, event reviews are highly routinized … event Occurs at: ■ 30 days ■ 60 days ■ 90 days 6 – System-Focused Event Investigation and Analysis … that led up to the event. 6. … Culture ■ Was this event placed in the patient safety event reporting system?

10. Vaccine Adverse Event Reporting System Reporting Form | Agency for Healthcare Research and Quality
    www.ahrq.gov/nursing-home/resources/vaccine-adverse-event-reporting.html
    August 01, 2022 - Vaccine Adverse Event Reporting System Reporting Form Resource: Vaccine Adverse Event Reporting … This webpage hosts a writable PDF form that provides instructions for reporting a vaccine adverse event

11. CANDOR Event Checklist | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/checklist4.html
    August 01, 2022 - a checklist for the required actions that need to be taken following an event. … : Hotline: Enter event report via the institution's event reporting system. … 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.

12. System-Focused Event Investigation and Analysis Guide | Agency for Healthcare Research and Quality
    www.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.

13. Event Investigation and Analysis Guide: Appendix I | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/api.html
    August 01, 2022 - Event Investigation and Analysis Guide: Appendix I Glossary Adverse safety event: a deviation … Causal factor: the suspected or confirmed factors that caused the adverse event. … Often, multiple factors must intersect for an adverse event to reach the patient. … Event review: the overall process of assessing an adverse safety event to determine contributing factors … In-depth event review: the data-gathering phase of an event review, involving conducting interviews,

14. National Healthcare Safety Network (NHSN) Laboratory-Identified Event (LabID Event): Surveillance for C. difficile Infection (CDI) and Drug-Resistant Organisms (MDROs) | Agency for Healthcare Research and Quality
    www.ahrq.gov/nursing-home/resources/nhsn-lab-id-event.html
    April 01, 2022 - National Healthcare Safety Network (NHSN) Laboratory-Identified Event (LabID Event): Surveillance for … Organisms (MDROs) Resource: National Healthcare Safety Network (NHSN) Laboratory-identified Event … (LabID Event): Surveillance for C. difficile infection (CDI) and drug-resistant organisms (MDROs) ​​

15. Event-Summary-Details-Maximizing-Physician-Buy-In (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/event-summary-details-maximizing-physician-buy-in.pdf
    June 16, 2022 - EVENT SUMMARY LEARNING COMMUNITY AFFINITY GROUP | SUMMARY AT-AT-GLANCE | 1 AFFINITY GROUP DETAILS … Format • A moderated panel discussion with three panelists, with additional input from over 70 event … System Director, Cardiac Rehabilitation, Lee Health Resource Link Slides and a recording of the event … EVENT SUMMARY LEARNING COMMUNITY AFFINITY GROUP | SUMMARY AT-AT-GLANCE | 2 OVERALL EVENT THEMES … EVENT SUMMARY LEARNING COMMUNITY AFFINITY GROUP | SUMMARY AT-AT-GLANCE | 3 DISCUSSION HIGHLIGHTS

16. Event-Summary-Leveraging-Data-Enhance-Cr-Program (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/event-summary-leveraging-data-enhance-cr-program.pdf
    November 12, 2020 - EVENT SUMMARY LEARNING COMMUNITY AFFINITY GROUP | SUMMARY AT-AT-GLANCE | 1 AFFINITY GROUP DETAILS … Format • A moderated panel discussion with two panelists, with additional input from the 120 event … EVENT SUMMARY LEARNING COMMUNITY AFFINITY GROUP | SUMMARY AT-AT-GLANCE | 2 ASSESSING THE CURRENT … PROGRAM OPERATION STATUS AT-A-GLANCE Current State Level of Uncertainty Participants in this event … OVERALL EVENT THEMES • Data access: In order to maximize CR enrollment and successful completion,

17. Voluntary Adverse Event Reporting in Rural Hospitals (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Schade_63.pdf
    January 01, 2007 - Voluntary Adverse Event Reporting in Rural Hospitals Voluntary Adverse Event Reporting in Rural Hospitals … The final list of event categories with definitions resulted from combination of similar event types … Event categories with <2 percent frequency are not shown. … Event Rates in Participating Hospitals Figure 1. … was not proportional to the risk of an event.

18. Exhibit 13. Probability of intervention reducing risk of surgical site infection (SSI) by multiple concurrent interventions at various reductions of noncompliance rates (25, 5 | Agency for Healthcare Research and Quality
    www.ahrq.gov/research/findings/final-reports/stpra/stpraexh13.html
    April 01, 2018 - References for Fault Tree Model Probability Estimates References Event Event … 30 Gate 239 Event 142 Event 659 Event 138 25% reduction in noncompliance Event 30 … puncture – – – 0.0042 0.0041 Event 138 Fail to remove watch/jewelry/fake nails – … puncture – – – 0.0040 0.0037 Event 138 Fail to remove watch/jewelry/fake nails – … puncture – – – 0.0039 0.0034 Event 138 Fail to remove watch/jewelry/fake nails –

19. Exhibit 9. Top five minimal cut sets for the basic case | Agency for Healthcare Research and Quality
    www.ahrq.gov/research/findings/final-reports/stpra/stpraexh9.html
    April 01, 2018 - reduction Event 142 (0.3) Staff not well-trained in infection control Event 450 (0.293) … Event 182 (0.2) Fail to administer indicated antibiotics Event 543 (0.0325) SSI risk for … reduction Event 142 (0.3) Staff not well-trained in infection control Event 450 (0.293) … Event 30 (0.125) Fail to prepare skin appropriately Event 543 (0.0325) SSI risk for obese … reduction Event 450 (0.293) Obese, but not diabetic, patient (30Event 642 (0.2)

20. Event Reporting and Learning System Leads to Improvements in Patient Safety Culture (Webcast) | Agency for Healthcare Research and Quality
    www.ahrq.gov/sops/events/webinars/unc-improvement-stories/index.html
    February 01, 2024 - Event Reporting and Learning System Leads to Improvements in Patient Safety Culture (Webcast) … Transcript Summary On Wednesday, December 18, 2019, AHRQ hosted a webcast that highlighted an event … Speakers discussed how implementation of a new event reporting system in UNC's outpatient Radiation Oncology … Building on this initial success, UNCMC embarked on a journey to improve the event reporting system and … YouTube embedded video: https://www.youtube-nocookie.com/embed/CJeMuRmkZoE Implementation of an Event