Event Investigation and Analysis Guide: Appendix C

Visual Model

Pt discharged to home without treatment for bacteremia, Readmitted one week later with sepsis. Discharging physician did not realize cultures were positive, No handoff between nocturnist and next physician covering patient. Handoff is inconsistently performed. Lab results unclear on microbiology screen. (+) plus sign used in multiple ways throughout the EMR. Interdisciplinary rounding not done on weekends. Interdisciplinary team unavailable on weekends, lower staffing patterns.

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 factors. The major contributing factors are the focus of the solutions meeting.

Return to Contents
Proceed to Appendix D

Return to CANDOR Contents

Page last reviewed February 2017
Page originally created April 2016
Internet Citation: Event Investigation and Analysis Guide: Appendix C. Content last reviewed February 2017. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module4-guide-apc.html