Event Investigation and Analysis Guide: Appendix D

CANDOR Tool

PROCESS QUESTIONS TO REVIEW Y/N CONTRIBUTING OR CAUSAL FACTOR Y/N FINDINGS /
COMMENTS
COMMUNICATION
  • Did all caregivers have access to all pertinent information needed to make the best decisions for the patient? (e.g., medical record, laboratory results, imaging, past medical history, test results, EHR)
  • If not, why?
  • Could this type of communication failure occur in the future during normal working conditions?
  • If yes, why?
     
COMMUNICATION
  • Was the medical record accurate and up to date, including necessary laboratory results, imaging, and test results?
  • If not, why?
  • Was it accessible and visible to the provider? How many charts were open? Was the software/system running properly?
     
COMMUNICATION
  • Are there any barriers to communication?
  • If yes, what are they? Why did they occur?
  • Is there any opportunity to overcome the barriers?
  • If not, why?
     
COMMUNICATION
  • Were staffing levels appropriate?
  • Were caregivers properly trained?
     
COMMUNICATION
  • Was there something that prevented information from being communicated effectively to the entire team in a timely manner?
     
COMMUNICATION
  • Was there a handoff involved in the event? What happened during the handoff? Was there anything that happened during the handoff that may have contributed to the event?
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PHYSICAL ENVIRONMENT
  • Describe the physical environment.
  • Was the physical environment conducive to providing safe care for this patient/procedure/event (e.g., lighting, overhead paging, security, uneven or slippery surfaces, visitors, emergency power, noise, alarm fatigue)?
     
PHYSICAL ENVIRONMENT
  • Was this a direct result of a natural disaster, and if so, is there an emergency response plan? Is emergency equipment tested on a regular basis?
     
EQUIPMENT DEVICE FAILURE
  • Was all necessary equipment available?
  • Did staff know where to find the equipment needed?
     
EQUIPMENT DEVICE FAILURE
  • Was all equipment functioning properly? 
  • Was the preventive maintenance and testing up to date?
  • Were there features of the device that made it difficult for users to understand how to properly operate the device?
  • Were there features of the device that facilitated error?
  • What was the training regimen for this device?
  • Have others (internal and external) reported problems with the device?
     
EQUIPMENT DEVICE FAILURE
  • If applicable, was this incident reported to the FDA?
     
EQUIPMENT DEVICE FAILURE
  • Was there a recall on this device?
     
CARE PROCESS
  • What are the steps in the process?
     
CARE PROCESS
  • Were there enough people to do the steps in the process?
  • Were they the right people to do those steps?
  • Identify the actual staffing ratio. Was it adequate?
  • Were any of the involved individuals working extended shifts (longer than 12 hours)?
     
CARE PROCESS
  • Did this event take place during a procedure, test, or skilled task?
  • If yes, how often are these particular competencies assessed?
  • If yes, is there a written protocol that the care provider could have referenced?
    • If yes, was it easily accessible and did the care provider know it was available?
    • If no, where was it located? Is it commonly requested? Is it commonly used?
     
CARE PROCESS

 

  • Were procedures available, workable, intelligible, and routinely used? If not, why?
     
CARE PROCESS
  • Could a similarly credentialed person do the same thing in a similar situation with the same information available (considering the environment)?
     
CARE PROCESS
  • Are there any known deviations from the standard? If so, was the standard known and easily understood? If so, was the standard applicable/feasible to the current work conditions?
     
CARE PROCESS
  • Was the team familiar with each other?
     
CARE PROCESS
  • Was there orientation for this individual or team? If yes, what was it like?
     
POLICY
  • Does a policy or procedure exist to address this process?
  • Was the policy followed? 
  • If not, why?
  • Is the policy feasible in the actual context of work?
  • Do people know about the policy? Was an appropriate roll out done?
  • Do leaders model that behavior? Has the policy been enforced by leaders?
  • If the answer to any of these questions is “no” this is a SYSTEMS issue and should be addressed as such.
     
CULTURE

 

  • What do you believe are the hospital’s/system’s priorities and goals?
  • How is patient safety discussed on your unit?
  • Did the involved party feel that there were conflicting priorities between keeping the patient safe and other organizational priorities?  
     
CULTURE
  • Have leaders established methods to identify risks and provide employees opportunities to make suggestions?
  • If yes, how?
     
CULTURE
  • Was this event communicated to the patient and family? 
  • If yes, who and what was communicated?
     
CULTURE
  • Was leadership contacted?
     
CULTURE
  • Is there any followup care being arranged for the patient and family?
     
CULTURE
  • Was this event placed in the patient safety event reporting system?
     
CULTURE
  • Was this event shared throughout the organization?
     
FUTURE RISKS
  • Are there other areas in the organization where this could happen?
     
FUTURE RISKS
  • Are there opportunities to improve trainings, competencies and orientation sessions by including lessons learned from this event?
     

 

CONTRIBUTING FACTORS SOLUTIONS TO CONTRIBUTING FACTORS RESPONSIBLE POSITION / TITLE IMPLEMENTATION DATE MEASUREMENT METHOD
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2.        
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Proceed to Appendix E

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Page last reviewed February 2017
Page originally created April 2016
Internet Citation: Event Investigation and Analysis Guide: Appendix D. 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-apd.html