7 Appendix G: Case Review Summary Form

Appendix G– Measure Dx Event Review Summary Form

Form Approved
OMB No. xxxx-xxxx
Exp. Date xx/xx/20xx

Appendix G– Measure Dx Event Review Summary Form

Measure Dx Event Review Summary Form

Instructions: The purpose of this form is to summarize the diagnostic safety intelligence that your team has detected, analyzed, and/or learned from while implementing one Measure Dx.

What you will need: Records you may need to complete this form include any spreadsheets or other tracking tools your team has used, completed case review tools, and documentation of your team’s response to the events you identified.

How to complete the form: In the boxes below, indicate which measurement strategy (or strategies) you implemented. For each strategy, provide a count for events in each of the following categories:

• Events identified or referred: the total number of events brought to the team’s awareness as a result of implementing the Strategy

• Events reviewed: the number of identified or referred events that were reviewed for improvement opportunities using the Revised Safer Dx Instrument (and other review methods, if applicable)

• Events with an improvement opportunity: the number of reviewed events that were identified as diagnostic safety events as defined below:

  • Delayed, Wrong, or Missed Diagnosis: There were one or more missed opportunities to pursue or identify an accurate and timely diagnosis (or other explanation) of the patient’s health problems based on the information that existed at the time; OR

  • Diagnosis Not Communicated to Patient: An accurate diagnosis (or other explanation) of the patient’s health problems was available, but it was not communicated to the patient (includes patient’s representative or family as applicable).

Additional space on the following page is provided to document any notable findings of high urgency or operational significance (eg, discovery of serious harm or significant system vulnerability warranting immediate action) and any actions taken in response to these findings.

Note: Your organization may have been collecting information about diagnostic safety events before starting this project. Please only count events that have been brought to your team’s attention since the date you agreed to take part in this project.

For which time period are you reporting event data?  Months 1-3  Months 3-6

 Did your team use Strategy A (Use Quality and Safety Data Already Collected by the Organization) during this time period? If so, answer the items below:
Events identified or referred Events reviewed Events with an improvement opportunity Did any events result in further action by the team?	Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text.  NO  YES  Complete next page
 Did your team use Strategy B (Solicit Reports from Clinicians and Staff) during this time period? If so, answer the items below:
Events identified or referred Events reviewed Events with an improvement opportunity Did any events result in further action by the team?	Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text.  NO  YES  Complete next page
 Did your team use Strategy C (Leverage Patient-reported Data) during this time period? If so, answer the items below:
Events identified or referred Events reviewed Events with an improvement opportunity Did any events result in further action by the team?	Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text.  NO  YES  Complete next page
 Did your team use Strategy D (Electronic Health Record-enhanced Chart Review) during this time period? If so, answer the items below:
Events identified or referred Events reviewed Events with an improvement opportunity Did any events result in further action by the team?	Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text.  NO  YES  Complete next page

Supplemental Form on Actions Taken in Response to Diagnostic Safety Events

Please provide a brief description of the event(s) identified and actions taken by the team or organization to reduce risk or mitigate harm. Do not provide any information that could possibly identify patients or involved providers.

Click or tap here to enter text.

This survey is authorized under 42 U.S.C. 299a. The confidentiality of your responses to this survey is protected by Sections 944(c) and 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C. 242m(d)].  Information that could identify you will not be disclosed unless you have consented to that disclosure. Public reporting burden for this collection of information is estimated to average 45 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 5600 Fishers Lane, Room #07W42, Rockville, MD 20857.