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Showing results for "event".

1. Module 4: Event Reporting, Event Investigation and Analysis | Agency for Healthcare Research and Quality
   www.cpsi.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
   www.cpsi.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 1: An Overview of the CANDOR Process | Agency for Healthcare Research and Quality
   www.cpsi.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.

4. NPSD Dashboards | Agency for Healthcare Research and Quality
   www.cpsi.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

5. Implementation Guide for the CANDOR Process | Agency for Healthcare Research and Quality
   www.cpsi.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)) .

6. Module 7: Resolution | Agency for Healthcare Research and Quality
   www.cpsi.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.

7. Ventilator-Associated Event Data Collection Tool | Agency for Healthcare Research and Quality
   www.cpsi.ahrq.gov/hai/tools/mvp/modules/vae/tool.html
   January 01, 2017 - Program Tools Mechanically Ventilated Patients Toolkit Ventilator-Associated Event … Telemedicine Universal ICU Decolonization Protocol Ventilator-Associated Event … ______     Unit __________ Use this tool to track your progress in reducing ventilator-associated event … 2017 Page originally created January 2017 Internet Citation: Ventilator-Associated Event

8. Event Investigation and Analysis Guide: Appendix D | Agency for Healthcare Research and Quality
   www.cpsi.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. CLABSI and CAUTI Learning Tools | Agency for Healthcare Research and Quality
   www.cpsi.ahrq.gov/hai/tools/clabsi-cauti-icu/implement/learning-tools.html
   April 01, 2022 - 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, 273.6 KB) CAUTI Event Report Tool (Word, 269.7 KB) CLABSI Learn

10. Communication and Optimal Resolution (CANDOR) | Agency for Healthcare Research and Quality
    www.cpsi.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

11. Using Simulation in TeamSTEPPS Training: Classroom Slides | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/teamstepps/simulation/simulationslides/simslides.html
    June 01, 2019 - Return to Top   Define Event Sets Event sets are the building blocks of a scenario Event sets … Each event set should not include more than one trigger event . … Event sets can be created by breaking a clinical procedure into chunks . … The event sets or behavior categories can be used to structure discussion. … Rule of thumb: Have a key event every 1 to 2 minutes of scenario time.

12. NPSD Data Spotlight - Patient Safety and COVID-19: A Qualitative Analysis of Concerns During the Public Health Emergency (pdf file)
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/npsd/data/spotlights/spotlight-ptsafety-and-covid-19.pdf
    November 01, 2021 - event, etc.). … Descriptive Text About the Event Referencing COVID-19 Fall Event COVID-19 precautions cause a delay … Other Event Too many things do. … Details of Event or Unsafe Condition, and Contributing Factor(s) for Event were analyzed during a pilot … Number of Records by the Category(s) Associated with the Event or Unsafe Condition Category of Event

13. Mod5-Disclosure-Checklist (pdf file)
    www.cpsi.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.

14. AHRQ Quality Indicators Prioritization Worksheet Example (pdf file)
    www.cpsi.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

15. The PSO Privacy Protection Center | Agency for Healthcare Research and Quality
    www.cpsi.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

16. Development and Usability Testing of the Agency for Healthcare Research and Quality Common Formats to Capture Diagnostic Safety Events (pdf file)
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/topics/development-and-usability-testing-common-formats.pdf
    January 01, 2022 - Agency for Healthcare Research and Quality (AHRQ) began the de- velopment of the Common Formats for Event … Results: Estimated completion time was 30 to 90 minutes per event. … The CFER-DS also offers a definition of a diagnostic safety event using concepts pro- posed in 2 prior … Participants were asked to complete the CFER-DS to simulate event reporting for 5 cases of diagnostic … DISCUSSION Standards for diagnostic safety event reporting are necessary to advance national-level

17. Sensemaking and Learn From Defects for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
    www.cpsi.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-from-defects-fac-guide.html
    July 01, 2023 - of "why's" to reach the root causes of the event. … the event from reaching the patient. … Harm that did not happen—No-harm event. Event did not reach the patient—Near-miss event. … An antecedent describes the preceding event, condition, or cause. … The tree is an interpretation of the event.

18. Event Investigation and Analysis Guide: Appendix F | Agency for Healthcare Research and Quality
    www.cpsi.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

19. AHRQ Hospital Survey on Patient Safety Culture: Items and Dimensions (pdf file)
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hsops-items-composites.pdf
    February 16, 2021 - Hospital management seems interested in patient safety only after an adverse event happens. … We are given feedback about changes put into place based on event reports. C3. … Number of Events Reported (No event reports, 1 to 2 event reports, 3 to 5 event report, 6 to 10 event … reports, 11 to 20 event reports, 21 event reports or more) G1. … In the past 12 months, how many event reports have you filled out and submitted?

20. Survey on Patient Safety (facility version) (pdf file)
    www.cpsi.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/facilscanform.pdf
    November 18, 2019 - 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 .......... … 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