-
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
On behalf of (insert executive sponsor name), we would like you to participate in our upcoming solutions meeting related to (describe safety event).
The solutions meeting will take place at (time) (date) (location).
…
-
www.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/apc.html
August 01, 2022 - Gap Analysis Facilitator's Guide: Appendix C
Gap Analysis Structured Interview Guide
To produce more consistently useful results, use structured interview questions. The facilitator should review the questions in advance to determine which questions are appropriate for each focus group session. It may help to…
-
www.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/apb.html
August 01, 2022 - Gap Analysis Facilitator's Guide: Appendix B
Gap Analysis Structured Interview Questions
The Gap Analysis Structured Interview Questions allow the facilitator to lead participants through a set of questions designed to elicit participant views on a variety of key policies and practices.
Leadership and Cul…
-
www.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/ape.html
August 01, 2022 - Gap Analysis Facilitator's Guide: Appendix E
Gap Analysis Report Template
The purpose of the Gap Analysis report is to call attention to common themes among the groups, as well as variations among the groups in their perceptions and degree of commitment to CANDOR principles. Findings should be used for target…
-
www.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/apd.html
August 01, 2022 - Gap Analysis Facilitator's Guide: Appendix D
Anonymous Reporting Tool
The Gap Analysis process relies heavily on key informant interviews and perspectives, which often take place in a focus group setting. Many times individuals have additional, more sensitive information to share, or information/observations …
-
www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/api.html
August 01, 2022 - Event Investigation and Analysis Guide: Appendix I
Glossary
Adverse safety event: a deviation from generally accepted performance standards that reaches the patient and results in moderate to severe harm or death.
Anchoring bias: the tendency to make all information fit into a preconceived story, causing…
-
www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/aph.html
August 01, 2022 - Event Investigation and Analysis Guide: Appendix H
Hierarchy of Solutions
Do solutions meet the following criteria:
Address the root cause/contributing factor.
Are specific and concrete.
Can be understood and implemented by a reader unfamiliar with the situation.
Will be tested or simulated prior to…
-
www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apg.html
August 01, 2022 - Event Investigation and Analysis Guide: Appendix G
Data Measurement Plan
Contributing Factor
Definition / Description
Current State
Goal State
Data Source
How will data be collected?
Who will collect the data?
Proposed dates for measure- ment
Long-term followup plan
Notes
Bottles…
-
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 Interviewed:
NAME
TITLE/ROLE
Nurse #1
Charge nurse
Nurse #2
RN
CNA X
Nursing tech
Manager MS
Manager
Pertinent Interview Findings
There was only one certifi…
-
www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apa.html
August 01, 2022 - Event Investigation and Analysis Guide: Appendix A
Five Whys
In this example, there is only one path shown, but answers can create multiple paths and more questions.
Event Summary: The wrong concentration of potassium (K+) was used in the compounding of TPN. This was discovered almost 2 months later.
1s…
-
www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apc.html
August 01, 2022 - Event Investigation and Analysis Guide: Appendix C
Visual Model
The model above is one major output from the in-depth review findings. This format helps to utilize the information found in the investigation to understand why the event occurred. The boxes represent different categories of contributing factor…
-
www.ahrq.gov/hai/tools/mvp/modules/sustainability/premortem-scorecard-slides.html
February 01, 2017 - Tools for Sustainability: Premortem and Scorecard: Slide Presentation
AHRQ Safety Program for Mechanically Ventilated Patients
Slide 1: AHRQ Safety Program for Mechanically Ventilated Patients
Tools for Sustainability: Premortem and Scorecard
Slide 2: Learning Objectives
After this session, you will…
-
www.ahrq.gov/hai/tools/mvp/modules/sustainability/communication-strategies-slides.html
February 01, 2017 - Communication Strategies for Sustainability: Slide Presentation
AHRQ Safety Program for Mechanically Ventilated Patients
Slide 1: AHRQ Safety Program for Mechanically Ventilated Patients
Communication Strategies for Sustainability
Slide 2: Learning Objectives
After reviewing this module, you will be…
-
www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4.html
August 01, 2022 - System-Focused Event Investigation and Analysis Guide
AHRQ Communication and Optimal Resolution Toolkit
Purpose : To help teams adopt a system-focused approached to event investigation and analysis.
Who should use this tool? Event Reporting, Investigation, and Analysis Team.
How to use this tool : Review…
-
www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide6.html
August 01, 2022 - Care for the Caregiver Program Implementation Guide
AHRQ Communication and Optimal Resolution Toolkit
Purpose: To guide an organization in developing and implementing a Care for the Caregiver program.
Who should use this tool? The Care for the Caregiver Program Lead
How to use this tool: Use this guide…
-
www.ahrq.gov/patient-safety/settings/hospital/candor/modules/checklist4.html
August 01, 2022 - CANDOR Event Checklist
AHRQ Communication and Optimal Resolution Toolkit
Purpose: To provide a checklist for the required actions that need to be taken following an event.
Who should use this tool? The Communication and Optimal Resolution (CANDOR) Response Team or designee, unless otherwise indicated.
…
-
www.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3.html
August 01, 2022 - Gap Analysis Facilitator's Guide
AHRQ Communication and Optimal Resolution Toolkit
Purpose: To evaluate the extent to which current processes align with the Communication and Optimal Resolution (CANDOR) process and includes:
Identifying the existing process.
Identifying the existing outcome(s).
Ide…
-
www.ahrq.gov/patient-safety/settings/hospital/candor/modules/checklist5.html
August 01, 2022 - Disclosure Checklist
AHRQ Communication and Optimal Resolution Toolkit
Purpose: To provide guidance to individuals who are conducting initial or followup disclosure conversations, including key disclosure communication skills.
Who should use this tool? Disclosure Lead and any staff who will be engaged in …
-
www.ahrq.gov/patient-safety/settings/hospital/candor/modules/worksheet2.html
August 01, 2022 - Building the Business Case for CANDOR Worksheet
AHRQ Communication and Optimal Resolution Toolkit
Purpose: To provide guidance to leaders and staff who are building a business case for implementing the Communication and Optimal Resolution (CANDOR) process in their organization.
Who should use this tool? …
-
www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/scenarios.html
August 01, 2022 - Case Scenarios: Handling Challenging Communications
AHRQ Communication and Optimal Resolution Toolkit
Purpose : To help you prepare for disclosure communications by using four scenarios to practice challenging interpersonal communications.
Who should use this tool? Disclosure Lead(s).
How to use this too…