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1. Module 4: Event Reporting, Event Investigation and Analysis | Agency for Healthcare Research and Quality
   www.qualitymeasures.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. CAUTI Event Reporting Tool (doc file)
   www.qualitymeasures.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.qualitymeasures.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.qualitymeasures.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. Innovations-Improve-Cr-Event-Summary (pdf file)
   www.qualitymeasures.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

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

7. Event-Summary-Details-Maximizing-Physician-Buy-In (pdf file)
   www.qualitymeasures.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

8. Event-Summary-Leveraging-Data-Enhance-Cr-Program (pdf file)
   www.qualitymeasures.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,

9. Dashboard Information | Agency for Healthcare Research and Quality
   www.qualitymeasures.ahrq.gov/npsd/data/dashboard/info.html
   June 01, 2019 - Reporting – Hospital Version (CFER-H) definitions of Adverse Events, i.e., the Common Formats Event … The event-specific modules provide additional and more detailed information about the following nine … The text of the NPSD Dashboards has been formatted to assist readers to better understand event types … Near miss: An event that did not reach a patient. … Unsafe condition: Any circumstance that increases the probability of a patient safety event; includes

10. Module 1: An Overview of the CANDOR Process | Agency for Healthcare Research and Quality
    www.qualitymeasures.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.

11. NPSD Dashboards | Agency for Healthcare Research and Quality
    www.qualitymeasures.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

12. Exhibit 9. Top five minimal cut sets for the basic case | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/research/findings/final-reports/stpra/stpraexh9.html
    April 01, 2018 - Event 142 (0.3) Staff not well-trained in infection control Event 450 (0.293) Obese, … Event 182 (0.2) Fail to administer indicated antibiotics Event 543 (0.0325) SSI risk for … during home care Event 433 (0.05) Patient has organism at postoperative visit Event 543 … Event 30 (0.125) Fail to prepare skin appropriately Event 543 (0.0325) SSI risk for obese … Event 450 (0.293) Obese, but not diabetic, patient (30Event 642 (0.2) Fail

13. Implementation Guide for the CANDOR Process | Agency for Healthcare Research and Quality
    www.qualitymeasures.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)) .

14. Device or Medical/Surgical Supply including Health Information Technology Dashboard (xls file)
    www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/npsd/Device_Dashboard_Data_2023.xlsx
    January 01, 2023 - Description Device_3 Device Event Description by Extent of Harm Device_4 HIT Device Related … to Event or Unsafe Condition Device_5 HIT Device Related to Event or Unsafe Condition by Extent … Device_3 Device_3: Device Event Description Device Event Description Percentage Frequency Total Unknown … Device_5 Device_5: HIT Device Related to Event or Unsafe Condition HIT Device Percentage Frequency … Device_6 Device_6: HIT Device Related to Event or Unsafe Condition by Extent of Harm HIT Device No

15. Exhibit 11. Importance measures on events in rank order of criticality | Agency for Healthcare Research and Quality
    www.qualitymeasures.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 … , but not diabetic, patient (30 < BMI < 40) 0.3147 0.0047 0.3147 Event 543 SSI risk for obese … 0.0070 0.2003 Event 456 Patient is a smoker and has COPD 0.1649 0.0135 0.1649 Event 659 … 0.1457 Event 138 Fail to remove watch/jewelry/fake nails 0.1291 0.0038 0.1291 Event 644 … 0.0995 0.0012 0.0995 Event 241 Tourniquet time >60min 0.0956 0.0051 0.0956 Event 660 Patient

16. 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.qualitymeasures.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 Fail to prepare … 142 Staff not well-trained in infection control – – 0.0041 0.0039 0.0039 Event 659 Glove … puncture – – – 0.0042 0.0041 Event 138 Fail to remove watch/jewelry/fake nails – – … 142 Staff not well-trained in infection control – – 0.0038 0.0035 0.0035 Event 659 Glove

17. Event Investigation and Analysis Guide: Appendix D | Agency for Healthcare Research and Quality
    www.qualitymeasures.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?      

18. CLABSI and CAUTI Learning Tools | Agency for Healthcare Research and Quality
    www.qualitymeasures.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

19. Communication and Optimal Resolution (CANDOR) | Agency for Healthcare Research and Quality
    www.qualitymeasures.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

20. Exhibit 10. Probability variations used in the sensitivity analyses | Agency for Healthcare Research and Quality
    www.qualitymeasures.ahrq.gov/research/findings/final-reports/stpra/stpraexh10.html
    April 01, 2018 - References for Fault Tree Model Probability Estimates References Event Probability … Event 28 Patient colonized with MRSA 0.10 to 0.30 Event 29 Non-MRSA patient 0.90 to 0.70 Event … 0.50 to 0.90 Event 182 Fail to administer indicated antibiotics (staff) 0.20 to 0.40 Event 203 … 0.15 to 0.50 Event 405 Patient understands, but does not follow, postoperative directions 0.10 … to 0.25 Event 622 Alcoholic patient fails to comply with instruction for not drinking prior to the