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1. Module 4: Event Reporting, Event Investigation and Analysis | Agency for Healthcare Research and Quality
   www.healthcare411.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.healthcare411.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. NPSD Dashboards | Agency for Healthcare Research and Quality
   www.healthcare411.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

4. Module 1: An Overview of the CANDOR Process | Agency for Healthcare Research and Quality
   www.healthcare411.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. Implementation Guide for the CANDOR Process | Agency for Healthcare Research and Quality
   www.healthcare411.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.healthcare411.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. Event Investigation and Analysis Guide: Appendix D | Agency for Healthcare Research and Quality
   www.healthcare411.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?      

8. Communication and Optimal Resolution (CANDOR) | Agency for Healthcare Research and Quality
   www.healthcare411.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

9. Using Simulation in TeamSTEPPS Training: Classroom Slides | Agency for Healthcare Research and Quality
   www.healthcare411.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.

10. NPSD Data Spotlight - Patient Safety and COVID-19: A Qualitative Analysis of Concerns During the Public Health Emergency (pdf file)
    www.healthcare411.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

11. Mod5-Disclosure-Checklist (pdf file)
    www.healthcare411.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.

12. AHRQ Quality Indicators Prioritization Worksheet Example (pdf file)
    www.healthcare411.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

13. The PSO Privacy Protection Center | Agency for Healthcare Research and Quality
    www.healthcare411.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

14. Sensemaking and Learn From Defects for Perinatal Safety: Facilitator Guide | Agency for Healthcare Research and Quality
    www.healthcare411.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.

15. Event Investigation and Analysis Guide: Appendix F | Agency for Healthcare Research and Quality
    www.healthcare411.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

16. Survey on Patient Safety (facility version) (doc file)
    www.healthcare411.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

17. Prioritization Worksheet (pdf file)
    www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/c1_pdi_prioritizationworksheetinstructions.pdf
    June 05, 2016 - Column F, “Cost of Single Event,” indicates the average cost to your organization of one event. … both costs and risk of the adverse event (e.g., concurrent cancer diagnosis). … Ideally, if your data permit, consider only costs that occur after the adverse event occurred. … 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?

18. Prioritization Worksheet (pdf file)
    www.healthcare411.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?

19. Sensemaking and Learn From Defects for Perinatal Safety | Agency for Healthcare Research and Quality
    www.healthcare411.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-from-defects-slides.html
    July 01, 2023 - Each person brings their experience of that event/issue to the discussion. … At the top of the tree and at the top row is the discovery event. … The discovery event addresses what happened. … Providers must also correct the factors that contribute to an event. … The attributes of medical event-reporting systems: Experience with a prototype medical event-reporting

20. Event Investigation and Analysis Guide: Appendix C | Agency for Healthcare Research and Quality
    www.healthcare411.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