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www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.pdf
May 01, 2017 - Sensemaking tools supply a systematic
approach to event reporting. … 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-
Slide 13
Sensemaking … The tree is an
interpretation of the event.
-
www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/c2_pdi_prioritizationworksheetexample.pdf
June 05, 2016 - Indicators Toolkit
Prepared by RAND and UHC for AHRQ Tool C.1
Volume of
Cases at
Risk
Cost of Single
Event … E F G H I J K L M N O P Q R
List of PDIs Own
Rate
National
Comparator
Annual
volume of
this event … Anticipated
average cost for
one case with
this event
The total annual
cost of this event
to … organization
Anticipated cost
to investigate/
implement new
process is less
than annual cost
of event … established
organizational
goals and
priorities
• Regulatory
• Value-based
purchasing
• Sentinel
event
-
www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/c1_pdi_prioritizationworksheet.pdf
June 05, 2016 - Indicators Toolkit
Prepared by RAND and UHC for AHRQ Tool C.1
Volume of
Cases at
Risk
Cost of Single
Event … E F G H I J K L M N O P Q R
List of PDIs Own
Rate
National
Comparator
Annual
volume of
this event … Anticipated
average cost for
one case with this
event
The total annual
cost of this event
to … organization
Anticipated cost
to investigate/
implement new
process is less
than annual cost
of event … established
organizational
goals and
priorities
• Regulatory
• Value-based
purchasing
• Sentinel
event
-
www.healthcare411.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.
-
www.healthcare411.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
-
www.healthcare411.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apb.html
August 01, 2022 - Patient Safety Resources by Setting
Hospital
Hospital Resources
CANDOR
Event … Patient Safety News and Events
Education & Training
Resources
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. … Page last reviewed August 2022
Page originally created April 2016
Internet Citation: Event
-
www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospitalscanform.doc
June 09, 2016 - 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
(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
-
www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/sops/quality-patient-safety/patientsafetyculture/hospitalscanform.pdf
December 22, 2017 - • 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 ......... … We are given feedback about changes put into place based on event
reports ......................... … 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 information
-
www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patientsafetyculture/hospital/resources/hospscanform.pdf
March 22, 2017 - • 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 ......... … We are given feedback about changes put into place based on event
reports ......................... … 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 information
-
www.healthcare411.ahrq.gov/hai/cusp/modules/patient-family-engagement/notes.html
September 01, 2013 - Immediate Response to an Adverse Event 4 Slide 24. … How to Communicate About an Adverse Event 6 Slide 26. … What if an Adverse Event Occurs on the Unit? … event, and the care provided as a result of the event … of emotions when an adverse event occurs.
-
www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/pqmp/toolkits/flow-diagrams.pdf
March 11, 2021 - DEC_TOTAL_MEM_LEVEL
Identify payer
details associated
with most recent
qualifying event
Sum event … DEC_IDENT_CE
Concatenate
denominator
month tables
10) AST1_OUT.DENOMINATOR_RAW_DATA
Deduplicate: 1
event … payer/member
combos that exist
in the denominator
Deduplicate so
that there is only 1
numerator event … asthma (ie - is in the denominator)
6If a qualified member has no numerator
events during a month, the event
-
www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/evidencenow/heart-health/strategies-to-better-manage-lipids.pptx
November 01, 2016 - Recommendation Grade
Adults ages 40-75 years with no symptoms or history of CVD and a calculated 10-year
CVD event … dyslipidemia, diabetes, hypertension, or smoking)
They have a calculated 10-year risk of a cardiovascular event … of 10% or
greater
Identification of dyslipidemia and calculation of 10-year CVD event risk requires … Recommendation Grade
Adults ages 40-75 years with no symptoms or history of CVD and a 10-year CVD event … statin use may be beneficial for the primary prevention of CVD events in some adults with a 10-year CVD event
-
www.healthcare411.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/pf-engagement-fac-guide.html
July 01, 2023 - Engaging after an adverse event.
Engaging in planning and design. … Immediately after an adverse event, care providers:
Provide care. … event, and the care provided as a result of the event. … a number of emotions when an adverse event occurs. … Rarely does an adverse event occur as a result of intent.
-
www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/c1_combo_prioritizationworksheet.xlsx
July 01, 2016 - disagree/low) Barrier Assessment (indicate Yes or No)
Volume of Cases at Risk Cost of Single Event … G H I J K L M N O P Q R
List of PSIs/IQIs/PDIs Own Rate National Comparator Annual volume of this event … Anticipated average cost for one case with this event The total annual cost of this event to our organization … Anticipated cost to investigate/ implement new process is less than annual cost of event Anticipated … with established organizational goals and priorities • Regulatory
• Value-based purchasing
• Sentinel event
-
www.healthcare411.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/pf-engagement-slides.html
July 01, 2023 - Discuss how to communicate an adverse event to a patient and family members. … Engaging after an adverse event.
Engaging in planning and design. … Slide 18: Immediate Response to an Adverse Event 4
Care for the patient. … Document the event in the medical record. … Slide 21: Next Steps in Responding to an Adverse Event 6
Investigation.
-
www.healthcare411.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/notes.html
August 01, 2022 - Define a CANDOR event.
Develop a measurement strategy. … Event Reporting, Investigation, and Analysis Team—responsible for reviewing the organization’s current … Slide 6
Say:
A CANDOR event is defined as an event that involves unexpected harm (physical, … As the culture begins to change, the organization can start to expand the definition of a CANDOR event … and Event Investigation and Analysis.
-
www.healthcare411.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apg.html
August 01, 2022 - Patient Safety Resources by Setting
Hospital
Hospital Resources
CANDOR
Event … Patient Safety News and Events
Education & Training
Resources
Event … Page last reviewed August 2022
Page originally created April 2016
Internet Citation: Event
-
www.healthcare411.ahrq.gov/patient-safety/quality-measures/qsrs/index.html
September 01, 2022 - Overall, the QSRS will generate adverse event rates and trend performance over time. … The QSRS also:
Offers an expanded array of adverse event measures, including ones related to opioid … standardized definitions and algorithms, consistent with those used by the AHRQ Common Formats for Event … This approach ensures that an event identified at one institution is the same as one identified elsewhere
-
www.healthcare411.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apa.html
August 01, 2022 - Patient Safety Resources by Setting
Hospital
Hospital Resources
CANDOR
Event … Patient Safety News and Events
Education & Training
Resources
Event … Event Summary: The wrong concentration of potassium (K+) was used in the compounding of TPN. … Page last reviewed August 2022
Page originally created April 2016
Internet Citation: Event
-
www.healthcare411.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/nursing-home/nursing-home-workplace-safety-resources.pdf
January 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 … /sentinel-event-alert-60-developing-a-reporting-culture-learning-from-
close-calls-and-hazardous-condi … /sentinel-event-alert-newsletters/sentinel-event-alert-60-developing-a-reporting-culture-learning-from-close-calls-and-hazardous-condi