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.

How to use this tool: Use the checklist to ensure that appropriate action is taken following an adverse event.

CANDOR Process Steps
Receipt of Report

How report was received:

  • Hotline: Enter event report via the institution's event reporting system.
  • Online: Review and prioritize events.
  • Complaint/Grievance: Gather facts, and refer to patient/guest relations or the appropriate department/individual.
Assess and Inform
  • Ensure the patient is stable, and provide emotional support to the patient/family.
  • Assess event for potential harm based on report/cursory electronic medical record review.
  • Report any adverse event to the appropriate professional responsible for patient safety events. Activate Care for the Caregiver program and provide emotional support for caregivers and staff.
Sequester Evidence
  • Secure the event location (i.e., patient room or procedural area).
  • Do not move, turn off, change equipment settings in:
    • Patient room/procedural area – do not allow anyone in the area.
    • All equipment and devices.
    • All disposables (e.g., medication vials, IV bags, catheters.
  • Contact clinical or biomedical engineering for assistance.
  • Obtain all records: medical record, departmental worksheets, logs (e.g., transports), and schedules (e.g., OR, on-call).
  • Identify all individuals involved in the event; determine via medical record review and interviews.
  • Note any evidence of additions, corrections, or alterations in the medical record (contact IT to assist with EMR).
  • Obtain all monitoring strips/records.
  • Secure record of pages via operator or tracking mechanism.
  • Secure photos/video recordings (OR/procedural) and/or security monitoring tape.


Initial Key Communications
  • Consider additional care provider referrals to Employee Assistance Program (EAP) and/or peer-support program.
  • Prepare strategy for ongoing communication with key stakeholders and patient/family.
  • Identify a patient/family liaison.
  • Advise care providers on appropriate medical record documentation post event.
  • Initiate process to hold hospital and professional fee billing.
  • Notify appropriate individuals of the event (e.g., claims management, legal counsel, any liability carrier that might be involved).
    • Assist legal counsel in gathering facts/information, as requested.
  • Notify residency program directors, as appropriate.
  • Contact the unit/program director of each employee to be interviewed.
Event Review
  • Schedule in-person interviews of key staff.
  • Determine best physical setting and arrangement for interview.
  • Prepare interview strategy, questions, and materials based on document review and event review handbook.
  • Outline the subject areas to be addressed in logical sequence.
  • Compose questions for each subject area.
  • Collect medical records and other documents to establish timeline of events.
  • Consider additional care provider referrals to EAP and/or peer-support program.
  • Provide interviewees with contact information of interviewer.


Steps for Investigation and Analysis
  • Identify any potential issues for peer review or other accountability review in accordance with just culture principles.
  • Develop investigation strategy.
  • Use the following as guidance:  Joint Commission's National Patient Safety Goals; National Quality Forum's Serious Reportable Events; or Centers fpr Medicare & Medicaid Services' "never" events.
  • Identify organizational policies and procedures that apply to the event to determine whether they:
    • Were followed, and/or
    • Are in need of revision.
  • Flow chart the process, if applicable.
  • Conduct a literature review, if applicable.
  • Enter all information in the hospital event reporting system.
  • Obtain peer review, as appropriate.
  • Keep leadership up-to-date on the process.
  • Continue to monitor patient/family status and needs.
  • Maintain contact with patient advocate/liaison.
Concluding the Investigation
  • Conduct consensus meeting with leadership and appropriate providers to review findings and determine next steps.
  • Meet with malpractice insurer(s) to review findings.
  • Implement changes to process, procedures and policies, as appropriate.
  • Monitor changes to ensure results.
  • In the final step, appropriate personnel will:
    • Meet with patient/family to review findings, present resulting actions to prevent future recurrences of similar events.
    • Determine if it is appropriate to continue to withhold some or all claims to third parties and bills to the patient.
  • Offer to discuss financial restitution to the patient / family, if appropriate.

Return to CANDOR Contents

Page last reviewed February 2017
Page originally created April 2016
Internet Citation: CANDOR Event Checklist. Content last reviewed February 2017. Agency for Healthcare Research and Quality, Rockville, MD.
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