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{"sheet":"Important update","index":0,"n_rows":17,"n_cols":1,"rows_kept":17,"cut":false,"hidden":false,"merged":[]}
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["Notes: "]
["Based on observations from the 2020 (year 5) submissions, the audit template has been updated to support EDRV to include relevant information."]
["The following features are enabled:*"]
[]
["1. For \"Type of AE(s)/Quality Issues\" users are able to select the 'primary response' and 'secondary response' should there be more than one applicable quality issue "]
["2. For \"Theme\" users are able to select the 'primary theme' and 'secondary theme' should there be more than one applicable theme"]
["3. For \"Intervention Type\" users are able to select the 'primary intervention type' and 'secondary intervention type' should there be more than one applicable theme"]
[]
["*In order to enable these features, macros MUST BE enabled."]
[]
["For an event (row), if selecting 'no further analysis required', NO additional information is required for that event (all subsequent cells should be blank)"]
["For an event (row), if selecting 'further analysis required', ALL additional information is required for that event (all subsequent cells should be completed)"]
[]
["Please label the excel file using the following convention (HOSPITAL NAME_SUBMISSION YEAR_EDRV AUDITS) and upload to QIP navigator.  "]
["Please click on, or copy and paste into your internet browser the following link for instructions on how to upload your audits to QIP Navigator: "]
["https://www.hqontario.ca/Portals/0/documents/qi/qip/2025-26-EDRVQP-and-QIP-program-integration-en.pdf "]

{"sheet":"Template","index":1,"n_rows":9,"n_cols":16,"rows_kept":9,"cut":false,"hidden":false,"merged":[[3,0,3,5],[3,6,3,13],[2,0,2,15]]}
[]
[]
["ED Return Visit Audit Template"]
["For completion By qualified health care provider ",null,null,null,null,null,"For completion by ED physician and treating team"]
["A","B","C","D","E","F","G","H","I","J","K","L","M","N","O","P"]
["Case #","Sentinel vs Non-Sentinel\np. 7","Sentinel Diagnosis\np. 7","Summary of Visit 1                             (Please describe what happened)\np. 7","Summary of Visit 2                                (Please describe what happened)\np. 7","Screening Result\np. 8","AE(s)/Quality Issue(s)\np. 10","Type(s) of AE(s)/Quality Issue(s)\np. 10- Primary response\n(REQUIRED)","Type(s) of AE(s)/Quality Issue(s)\np. 10- Secondary response\n(OPTIONAL)","Impact (severity of harm)\np. 11","Underlying Cause(s)\np. 12","Theme\np. 12- Primary response\n(REQUIRED)","Theme\np.12- Secondary response\n(OPTIONAL)","Potential Actions for Quality Improvement\np. 13","Intervention Type\np. 13- Primary response\n(REQURIED)","Intervention Type\np. 13- Secondary response\n(OPTIONAL)"]
[null,"Non-Sentinel",null,"Patient presents to ED with 5 days abdominal pain, no fever, lab work normal but some peritoneal findings. EP review of abdominal CT is normal; not reviewed by diagnostic imaging. Patient advised that doctor will call if CT abnormal","Patient called back to ED after official review of CT shows a perforated duodenum. Patient admitted.","Further analysis required","Yes","Unsafe discharge disposition or decision","Suboptimal discharge follow up","Moderate","11 hour delay from CT to review by radiology. Patient requested to go home and wait for read.","Handover/ Communication between providers","Imaging/ Testing availability","Policy required re: maximum time  from scan to report.  Automatic notification to ED and DI when time expired. Escalation process required,","Simplification and standardization","Rules and policies"]
[null,"Non-Sentinel",null,"Child with fever and dry cough X4 days. Taking amoxicillin for otitis. Patient tachycardic, well perfused, chest clear no WOB. CXR shows pneumonia. Patient discharged home on increased dose of amoxicillin. Vital signs not reassessed upon discharge.","Patient returns, fever and cough persisted. Patient tachycardic and tachypneic with decreased air entry to left lower lobe, spo2 95% on RA. IV+ BW+ Bolus+ amoxicillin administered. Patient admitted for positive mycoplasma pneumonia x3 days, no supplemental oxygen required during admission.","Further analysis required","Yes","Management of patient","Procedural complication","None","Patient discharged home tachycardic , vital signs were not reassessed.","High risk medications or medication interactions","Discharge planning/ Community follow up","Hard stop implemented within our EMR to require providers to enter in rationale for elevated vital signs upon discharge/ prompt for patient reassessment. ","Forcing functions","Education and training"]
[null,"Non-Sentinel",null,"Elderly patient arrived to ED via EMS due to sudden severe headache while straining.  Headache reported as much improved at time of triage assessment. CTAS 2.  Patient was noted to have left without being seem 3h later.","Patient presented to another ED within 72h and diagnosed with SAH","Further analysis required","Yes","Management of patient","Medication adverse event","Severe","Very concerning story in older patient.  No follow up done after patient was unable to be found in the ED waiting room.","Radiology","Physician Cognitive Lapse","All patients who leave prior to MD assessment need to have the triage notes reviewed, ideally by the charge RN or recall MD, several times per day.  Concerning triage notes, abnormal vitals or other causes for concern should mandate phone calls to the patient, next of kin, and if necessary - to the police to ensure patient's well being","Automation and computerization","Simplification and standardization"]

{"sheet":"Drop-down lists","index":2,"n_rows":13,"n_cols":14,"rows_kept":13,"cut":false,"hidden":true,"merged":[]}
[]
["Institution Name","Institution number","Sentinel vs Non-Sentinel\np. 7","Sentinel Diagnosis\np. 7","Summary of Visit 1 (Please describe what happened)\np. 7","Summary of Visit 2 (Please describe what happened)\np. 7","Screening Result\np. 8","AE(s)/Quality Issue(s)\np. 10","Type(s) of AE(s)/Quality Issue(s)\np. 10","Impact (severity of harm)\np. 11","Underlying Cause(s)\np. 12","Theme\np. 12","Potential Actions for Quality Improvement\np. 13","Intervention Type\np. 13"]
[null,null,"Sentinel","AMI",null,null,"No further analysis required","Yes","Diagnosis","None",null,"Patient risk profile/ patient factors",null,"Forcing functions"]
[null,null,"Non-Sentinel","SAH",null,null,"Further analysis required","No","Management of patient","Mild",null,"Elder Care",null,"Automation and computerization"]
[null,null,null,"Pediatric sepsis",null,null,null,null,"Medication adverse event","Moderate",null,"LAMA or LWBS",null,"Simplification and standardization"]
[null,null,null,null,null,null,null,null,"Procedural complication","Severe",null,"Documentation",null,"Reminders, checklists, and double-checks"]
[null,null,null,null,null,null,null,null,"Suboptimal discharge follow up","Death",null,"Handover/ Communication between providers",null,"Rules and policies"]
[null,null,null,null,null,null,null,null,"Unsafe discharge disposition or decision","Unable to determine",null,"High risk medications or medication interactions",null,"Education and training"]
[null,null,null,null,null,null,null,null,"Access / Service not available",null,null,"Vital signs abnormal or not documented"]
[null,null,null,null,null,null,null,null,null,null,null,"Physician Cognitive Lapse"]
[null,null,null,null,null,null,null,null,null,null,null,"Radiology"]
[null,null,null,null,null,null,null,null,null,null,null,"Imaging/ Testing availability"]
[null,null,null,null,null,null,null,null,null,null,null,"Discharge planning/ Community follow up"]

{"sheet":"Underlying Cause Themes","index":3,"n_rows":12,"n_cols":3,"rows_kept":12,"cut":false,"hidden":false,"merged":[]}
["Theme","Description","Example"]
["Patient risk profile/ patient factors","Failure to account for high-risk characteristics of patients (e.g., age, comorbidities, psycho-social status, etc.) when determining evaluation and management","40 day old patient presenting with inconsolable crying and irritability, no consideration or evaluation for sepsis, and had return visit to another hospital and found to have E. coli meningitis"]
["Elder care","Failure to consider unique presentations and needs of elder patients","81 yr old from nursing home; had an unwitnessed fall causing fracture of patella; treated conservatively with Zimmer splint; discharged back to NH. Returned next day, confused. CT scan showed subdural hematoma, as a result of the first fall. Patient admitted for monitoring"]
["LAMA or LWBS","Patients who left against medical advice or who left without being seen","37 year old presented to ER. Prolonged wait time and LWBS recorded after 4 hours. No retriage. Patient returned with meningitis; admitted to ICU."]
["Documentation","Suboptimal documentation, which may have contributed to the return visit that the patient experienced","Patient’s positive troponin was not documented in the chart, and it is unclear whether the MD had seen it; patient returned 5hrs later for admission"]
["Physician cognitive lapses","Knowledge gap or failure to act on signs and symptoms","Immunocompromised patient presents with abdominal pain after recent bowel perforation. MD failed to consider intra-abdominal abscess and performed an abdominal plain film"]
["High-risk medications or medication interactions","Failure to account for high-risk medications in assessment and management","Xarelto prescribed to patient with increased creatinine level (this med contraindicated with elevated creatinine levels)"]
["Vital signs abnormal or not documented","Failure to explain abnormal vital signs or vital signs that are not repeated for many hours during stay in ED and/or prior to discharge","Patient with chronic A.fib and heart rate of 126 at triage (not re-documented or re-checked during visit). Presented with lightheadedness in setting of URTI, discharged home with plan to see GP after long weekend. Patient had syncopal episode at home (HR on return visit of 155) and sustained head injury requiring admission. "]
["Handovers/communication between providers","Suboptimal communication, especially during handovers or between physicians and nurses","Nursing documentation states patient reports this is the worst headache of their life but in MD documentation patient states similar headache in past"]
["Radiology","Failure to diagnose correctly by the emergency physician, to communicate by the radiologist, or to appropriately note discrepancies in a timely manner","Patient visited ER with LLQ abdominal pain and had a CT abdo to rule out diverticulitis. Initial radiologist read was negative. Pt was discharged home with a diagnosis of abdo pain NYD. Next day, patient called back as the radiologist reinterpreted the CT as a query sigmoid volvulus. Pt was admitted to surgery and eventually underwent colostomy for treatment of volvulus"]
["Imaging/testing availability","Availability of timely access to imaging or other tests, i.e. after hours","Patient presented in evening hours with RLQ abdominal pain brought back next day for ultrasound; +diagnosis of appendicitis"]
["Discharge planning/community follow-up","Failing to assess baseline functioning, ability to cope, and support systems available prior to discharge from the ED, as well as availability of follow-up care in the community","Patient with chest pain was discharged to follow-up with cardiologist, but cardiologist was not available for 2 months"]

{"sheet":"Intervention Types","index":4,"n_rows":11,"n_cols":3,"rows_kept":11,"cut":false,"hidden":false,"merged":[]}
["Intervention Type*","Description","Example"]
["Forcing functions","This represents the most powerful way to change behaviour because it is designed to limit the user’s ability to deviate from a planned course of action.","Creating a force function at triage requiring  all patients to have a sepsis screen/trigger tool completed in order to complete triage process."]
["Automation and computerization","These address human fallibility (including reliance on memory) for simple, routine and/or repetitive tasks.","Creating a visual cue that appears on the electronic patient tracking board to remind clinicians to consider sepsis for patients who meet sepsis criteria on their triage vital signs."]
["Simplification and standardization","These decrease variability and simplify complex steps by bundling them into a single decision or action.","Creating an order set for patients with sepsis, which encourages evidence-based care by providing suggestions of timely IVF and antibiotic therapy depending on the presumed source of sepsis."]
["Reminders, checklists and double-checks","These increase redundancy and include methods to remind providers of the necessity to perform certain actions.","Creating conspicuous posters about sepsis in the physician lounge (e.g., “Have you ordered antibiotics within three hours for sepsis?”)."]
["Rules and policies","These can help resolve complex issues at the organizational level. They are often very detailed, but the details are usually poorly understood by users, who may forget or disregard them.","Adopting a medical directive that stipulates nurses should draw sepsis panel blood work, start an intravenous normal saline bolus and administer acetaminophen before physician evaluation on all patients meeting sepsis criteria."]
["Education and training","These are an essential part of a comprehensive change initiative in that they are the most powerful way to create motivation for action, but alone they are often insufficient to achieve and sustain the level of change that is desired.","Developing a multi-modal education strategy (e.g., physician rounds, nursing huddles, monthly emails, etc.) may help attune providers to the importance of the problem."]
[]
["Adapted from: Chartier L, Stang A, Vaillancourt S, Cheng A. Quality improvement primer part 2: executing a quality improvement project in the emergency department. CJEM, In press. 2017."]
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["*Please note that you do not need to propose an intervention for every AE/quality issue you uncover. In these cases, please leave the \"Potential Actions for Quality Improvement\" and \"Intervention Type\" columns blank."]