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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apf.htmlAugust 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). …
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/apc.htmlAugust 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…
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/apb.htmlAugust 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…
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/ape.htmlAugust 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…
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3/apd.htmlAugust 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 …
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/api.htmlAugust 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…
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/aph.htmlAugust 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…
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apg.htmlAugust 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…
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apb.htmlAugust 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…
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apa.htmlAugust 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…
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apc.htmlAugust 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…
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www.ahrq.gov/hai/tools/mvp/modules/sustainability/premortem-scorecard-slides.htmlFebruary 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…
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www.ahrq.gov/hai/tools/mvp/modules/sustainability/communication-strategies-slides.htmlFebruary 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…
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4.htmlAugust 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…
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide6.htmlAugust 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…
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/checklist4.htmlAugust 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. …
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/facguide3.htmlAugust 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…
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/checklist5.htmlAugust 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 …
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/worksheet2.htmlAugust 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? …
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide5/scenarios.htmlAugust 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…
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