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21. Exhibit 10. Probability variations used in the sensitivity analyses | Agency for Healthcare Research and Quality
    www.ahrq.gov/research/findings/final-reports/stpra/stpraexh10.html
    April 01, 2018 - Range Considered Event 21 Patient fails to follow instructions for smoking cessation 0.13 to … 0.30 Event 28 Patient colonized with MRSA 0.10 to 0.30 Event 29 Non-MRSA patient 0.90 … to 0.70 Event 136 Fail to wash hands properly (OR staff) 0.12 to 0.40 Event 142 Staff … (staff) 0.20 to 0.40 Event 203 Fail to wash hands (non-OR staff) 0.10 to 0.60 Event … 404 Poor postoperative directions to patient 0.15 to 0.50 Event 405 Patient understands, but

22. Exhibit 11. Importance measures on events in rank order of criticality | Agency for Healthcare Research and Quality
    www.ahrq.gov/research/findings/final-reports/stpra/stpraexh11.html
    April 01, 2018 - Birnbaum Fussell– Vesely Event 642 Fail to protect patient effectively (failure related … to skin prep, antibiotics admin, shaving surgical site, etc.) 0.5187 0.0113 0.5187 Event … 450 Obese, but not diabetic, patient (30 < BMI < 40) 0.3147 0.0047 0.3147 Event 543 SSI … Event 659 Glove puncture 0.1550 0.0038 0.1550 Event 30 Fail to prepare skin appropriately … Event 419 Patient fails to come for post-op visit 0.1162 0.0034 0.1162 Event 136 Fail

23. Dashboard Information | Agency for Healthcare Research and Quality
    www.ahrq.gov/npsd/data/dashboard/info.html
    June 01, 2019 - Dashboard Information NPSD Dashboards display data that follow the Common Formats for Event Reporting … – Hospital Version (CFER-H) definitions of Adverse Events, i.e., the Common Formats Event Descriptions … There are 10 CFER-H modules: one Generic module applies to all reported events, and nine event-specific … The event-specific modules provide additional and more detailed information about the following nine … Near miss: An event that did not reach a patient.

24. Exhibit 3. Reporting of patient safety events | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/patients-families/consumer-exp/reporting/exh3.html
    August 01, 2022 - Information about the event flows to system users: primary system audience of consumers; and other potential … Type of event: harm event, no harm event, near miss. … Event details: who, what, where, etc. (Use structured input in a common reporting format.) … Reporting can be at any time, during or after the event. … real-time reporting, but caution reporters that the system is not a substitute for calling 911 in the event

25. Exhibit 2.9. Lean Project Activities | Agency for Healthcare Research and Quality
    www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit2-9.html
    November 01, 2014 - Pre-event Create charter. Select team members. … Prepare individuals for their roles in Lean event. … Post-RCI Event Implement all changes on Monday following the event (sometimes sooner). … Track event week metrics and post in common area. … Send out weekly communications and updates to staff during 1st month after the event.

26. Hospital Evacuation Decision Guide (Table 6) | Agency for Healthcare Research and Quality
    www.ahrq.gov/research/shuttered/hospevactab6.html
    July 01, 2018 - Implications Event Characteristics Arrival When is the event expected to … How variable is the time the event is expected to "hit"? … Magnitude What is the expected strength of the event? … Duration How long is the event expected to last? … How variable is the expected duration of the event?

27. Module 6: Care for the Caregiver | Agency for Healthcare Research and Quality
    www.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.

28. Hospital Evacuation Decision Guide | Agency for Healthcare Research and Quality
    www.ahrq.gov/research/shuttered/hospevac4.html
    July 01, 2018 - This resource was part of AHRQ's Public Health Emergency Preparedness program, and focused on post-event … Post-Event Evacuation Decision Guide Post-event evacuations have occurred either following Advanced … Figure 2 shows a flowchart that illustrates the post-event evacuation decision process. … post-event evacuations. … As was the case with the sequence in pre-event evacuations, with many post-event evacuations the most

29. Event Investigation and Analysis Guide: Appendix E | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/ape.html
    August 01, 2022 - Event Investigation and Analysis Guide: Appendix E Confirmation and Consensus Meeting Announcement … 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.

30. Event Investigation and Analysis Guide: Appendix F | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apf.html
    August 01, 2022 - Event Investigation and Analysis Guide: Appendix F Solutions Meeting Announcement Template … 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

31. CLABSI and CAUTI Learning Tools | Agency for Healthcare Research and Quality
    www.ahrq.gov/hai/tools/clabsi-cauti-icu/implement/learning-tools.html
    February 01, 2025 - They both support a thorough review of the event to identify and address the defect of the infection. … The event reporting tools have a comprehensive list of questions specific to CLABSI and CAUTI. … CLABSI Event Report Tool ( Word , 274 KB) CAUTI Event Report Tool ( Word , 270 KB) CLABSI Learn From

32. Implementation of an Event Reporting and Learning System Leads to Improvements in Patient Safety Culture at UNC Medical Center-Fenton-Wilhelm-Amos (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/sops/events/webinar/4-unc-webcast-fenton-wilhelm-amos.pdf
    August 15, 2019 - Implementation of an Event Reporting and Learning System Leads to Improvements in Patient Safety Culture … 32 U N C H E A L T H C A R E U N C H E A L T H C A R E Perceived barriers to event … reporting software • Double event report submissions by 100% within three years • Increase SOPS scores … in Feedback, Nonpunitive response and Event Reporting by 2021 35 U N C H E A L T H C … Reporting Platform Goal: To develop optimized interface for our event reporting software for event

33. Event Investigation and Analysis Guide: Appendix I | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/capacity/candor/modules/guide4/api.html
    February 01, 2017 - Event Investigation and Analysis Guide: Appendix I Adverse safety event: a deviation from … 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,

34. Notification of Adverse Event: Video | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/capacity/candor/videos/notification.html
    February 01, 2017 - Notification of Adverse Event: Video Communication and Optimal Resolution (CANDOR) is a … This video demonstrates an example of caregivers notifying the CANDOR team of an adverse event.

35. Exhibit 12. Probability of an intervention reducing the risk of surgical site infection (SSI) by interventions targeting component failure points individually | Agency for Healthcare Research and Quality
    www.ahrq.gov/research/findings/final-reports/stpra/stpraexh12.html
    April 01, 2018 - References for Fault Tree Model Probability Estimates References Event Original … noncompliance 75% reduction in noncompliance Original Probability of SSI 0.0044       Event … 0.0625 0.0313 Gate 239 Antibiotics related failure 0.3000 0.2250 0.1500 0.0750 Event … 142 Staff not well-trained in infection control 0.3000 0.2250 0.1500 0.0750 Event 659 … Glove puncture 0.1800 0.1350 0.0900 0.0450 Event 138 Fail to remove watch/jewelry/fake

36. Mapping a Large Patient Safety Database to the 2005 Patient Safety Event Taxonomy (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Clarke_8.pdf
    January 25, 2008 - These event types drive the collection of information germane to a specific event. … as a near-miss or “serious event”; the clinical event type according to the PA-PSRS taxonomy used in … PA-PSRS; the procedure involved; how the event was discovered; the disposition of the event; and the … 75.5 Date of admission 37.9 Type (near-miss or serious event) 37.6 How was event discovered 37.6 … Event type (modified UHC taxonomy) 37.6 Disposition of event 37.6 Procedure error: Procedure 30.0

37. Event Investigation and Analysis Guide: Appendix D | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apd.html
    August 01, 2022 - Event Investigation and Analysis Guide: Appendix D CANDOR Tool PROCESS QUESTIONS TO … 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?      

38. Event Investigation and Analysis Guide: Appendix B | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apb.html
    August 01, 2022 - 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.

39. Final progress report: Developing Evidence for Safety Surveillance from Device Adverse Event Reports (pdf file)
    www.ahrq.gov/sites/default/files/2025-02/mao-report.pdf
    January 01, 2025 - Final progress report: Developing Evidence for Safety Surveillance from Device Adverse Event Reports … Final progress report Developing Evidence for Safety Surveillance from Device Adverse Event Reports … Due to the narrative nature of device adverse event reports, research using them is limited. … Overall, we found that the number of adverse event reports increased significantly over time. … Vaccine adverse event text mining system for extracting features from vaccine safety reports.

40. Mixed Methods Analysis of Medical Error Event Reports: A Report from the ASIPS Collaborative (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Harris.pdf
    June 30, 2004 - event) or a “0” (not assigned to that event). … In addition to qualitatively coding event narratives, we developed flow charts of event activities for … questions about the event. … event Fixed choice (Yes/No) + optional brief narrative Was a system involved in the event? … • Describe the event. • Lead to or affect the downstream outcome of the event.