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The Patient Safety Standards ProjectReporting, review, disclosure, resolution, and clinician support — sourced to primary authority.

Every figure in The Patient Safety Standards Project, traced to its source

46 primary sources. Each URL was checked before publication and is rechecked whenever a page in The Patient Safety Standards Project is revised.

The numbered markers throughout the Center overview and the standards link to the matching entry below. Where a source has been superseded or withdrawn, the entry is corrected on the page rather than quietly removed — the editorial policy explains how.

  1. 1.Communication and Optimal Resolution (CANDOR). https://www.ahrq.gov/patient-safety/settings/hospital/candor/index.htmlAgency for Healthcare Research and Quality
  2. 2.CANDOR Toolkit — the eight modules, the $23 million Patient Safety and Medical Liability Grant Initiative launched in 2009, the 14 pilot hospitals, and AHRQ's estimate that about 1 in 10 patients is harmed by care. https://www.ahrq.gov/patient-safety/settings/hospital/candor/modules.htmlAgency for Healthcare Research and Quality
  3. 3.CANDOR Toolkit — Acknowledgments (National Project Team and Expert Faculty). https://www.ahrq.gov/patient-safety/settings/hospital/candor/acknowledgements.htmlAgency for Healthcare Research and Quality
  4. 4.42 CFR § 482.21 — Condition of participation: Quality assessment and performance improvement program (as amended at 89 FR 94591, Nov. 27, 2024). https://www.law.cornell.edu/cfr/text/42/482.21Legal Information Institute, Cornell Law School
  5. 5.Never Events Policy — the nine commitments. https://www.leapfroggroup.org/influencing/never-eventsThe Leapfrog Group
  6. 6.Adverse Events in Hospitals: A Quarter of Medicare Patients Experienced Harm in October 2018 (OEI-06-18-00400, May 2022). https://oig.hhs.gov/oei/reports/OEI-06-18-00400.pdfU.S. Department of Health and Human Services, Office of Inspector General
  7. 7.RCA²: Improving Root Cause Analyses and Actions to Prevent Harm (first published June 2015; Version 2, January 2016) — the full report, including the Action Hierarchy. https://www.ihi.org/sites/default/files/RCA2_ImprovingRootCauseAnalysesandActionstoPreventHarm.pdfNational Patient Safety Foundation / Institute for Healthcare Improvement
  8. 8.Disclosure of Errors — Patient Safety Primer. https://psnet.ahrq.gov/primer/disclosure-errorsAHRQ Patient Safety Network
  9. 9.Second Victims: Support for Clinicians Involved in Errors and Adverse Events — Patient Safety Primer. https://psnet.ahrq.gov/primer/second-victims-support-clinicians-involved-errors-and-adverse-eventsAHRQ Patient Safety Network
  10. 10.Boysen PG II, “Just Culture: A Foundation for Balanced Accountability and Patient Safety,” Ochsner Journal 13(3):400–406 (2013). https://pmc.ncbi.nlm.nih.gov/articles/PMC3776518/Ochsner Journal, via PubMed Central
  11. 11.Krevat SA, Samuel S, Boxley C, Mohan V, Siegal D, Gold JA, Ratwani RM, “Identifying Electronic Health Record Contributions to Diagnostic Error in Ambulatory Settings Through Legal Claims Analysis,” JAMA Network Open (2023). https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2803899JAMA Network Open
  12. 12.Bates DW, Levine DM, Salmasian H, et al., “The Safety of Inpatient Health Care,” New England Journal of Medicine 388:142–153 (2023). https://www.nejm.org/doi/full/10.1056/NEJMsa2206117New England Journal of Medicine
  13. 13.CRICO's 12-Step Diagnostic Process of Care Framework (first published December 17, 2014). https://www.rmf.harvard.edu/Risk-Prevention-and-Education/Article-Catalog-Page/Articles//2014/cbs-diagnostic-process-of-care-twelve/CRICO Strategies / Harvard Risk Management Foundation
  14. 14.The Center for Harm Response — a nonprofit supported by experts at the University of Washington and the Johns Hopkins Armstrong Institute. https://harmresponse.org/The Center for Harm Response
  15. 15.Medical Care Availability and Reduction of Error (MCARE) Act, Act 13 of 2002, § 308(b), 40 P.S. § 1303.308(b) — written notification to the patient within seven days of a serious event. https://www.palegis.us/statutes/unconsolidated/law-information/view-statute?txtType=PDF&SessYr=2002&SessInd=0&ActNum=0013.&chpt=3&subchpt=000.Pennsylvania General Assembly
  16. 16.CANDOR Toolkit — Implementation Guide: the five components of the CANDOR process, the definition of a CANDOR event, the 60-minute initial disclosure and 30–45 day investigation, and the 12–18 month implementation expectation. https://www.ahrq.gov/patient-safety/settings/hospital/candor/impguide.htmlAgency for Healthcare Research and Quality
  17. 17.CANDOR Toolkit Module 4 — System-Focused Event Investigation and Analysis Guide. https://www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4.htmlAgency for Healthcare Research and Quality
  18. 18.Sentinel Event Policy (SE), Comprehensive Accreditation Manual for Hospitals, CAMH Update 1, July 2026 — the 45-business-day comprehensive systematic analysis and corrective action plan. https://digitalassets.jointcommission.org/api/public/content/4035922bcc2f41bd83fbc1f55764a7b4?v=bf31f43bThe Joint Commission
  19. 19.Sentinel Event Policy and Procedures — definition of a sentinel event and the voluntary-reporting statement (archived January 15, 2025). https://web.archive.org/web/20250115083725/https://www.jointcommission.org/resources/sentinel-event/sentinel-event-policy-and-procedures/The Joint Commission, via the Internet Archive
  20. 20.Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries (OEI-06-09-00090, November 2010) — 13.5 percent adverse events and an additional 13.5 percent temporary harm events in October 2008, 44 percent preventable. https://oig.hhs.gov/oei/reports/oei-06-09-00090.pdfU.S. Department of Health and Human Services, Office of Inspector General
  21. 21.Never Events — Patient Safety Primer (the National Quality Forum list of 29 serious reportable events in 7 categories). https://psnet.ahrq.gov/primer/never-eventsAHRQ Patient Safety Network
  22. 22.Hospital-Acquired Conditions — the Deficit Reduction Act provision and the fourteen HAC categories. https://www.cms.gov/medicare/payment/hospital-acquired-conditions-hacCenters for Medicare & Medicaid Services
  23. 23.Surveys on Patient Safety Culture (SOPS) Hospital Survey 2.0 — Items and Composite Measures. https://www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospitalsurvey2-items.pdfAgency for Healthcare Research and Quality
  24. 24.High Reliability — Patient Safety Primer. https://psnet.ahrq.gov/primer/high-reliabilityAHRQ Patient Safety Network
  25. 25.Chassin MR, Loeb JM, “High-Reliability Health Care: Getting There from Here,” Milbank Quarterly 91(3):459–490 (2013). https://pmc.ncbi.nlm.nih.gov/articles/PMC3790522/Milbank Quarterly, via PubMed Central
  26. 26.Kachalia A, Kaufman SR, Boothman R, et al., “Liability Claims and Costs Before and After Implementation of a Medical Error Disclosure Program,” Annals of Internal Medicine 153(4):213–221 (2010). https://pubmed.ncbi.nlm.nih.gov/20713789/Annals of Internal Medicine, via PubMed
  27. 27.Kachalia A, Sands K, Van Niel M, et al., “Effects Of A Communication-And-Resolution Program On Hospitals' Malpractice Claims And Costs,” Health Affairs 37(11):1836–1844 (2018). https://pubmed.ncbi.nlm.nih.gov/30395501/Health Affairs, via PubMed
  28. 28.Colorado CANDOR Act, C.R.S. Title 25, Article 51 (SB 19-201), effective July 1, 2019. https://content.leg.colorado.gov/sites/default/files/2019a_201_signed.pdfColorado General Assembly
  29. 29.Iowa Code Chapter 135P — Adverse Health Care Incidents: Communications, Confidentiality (2015 Acts, ch. 33). https://www.legis.iowa.gov/docs/code/135P.pdfIowa Legislature
  30. 30.Utah Medical Candor Act, Utah Code Title 78B, Chapter 3, Part 4a, effective May 4, 2022. https://le.utah.gov/xcode/Title78B/Chapter3/C78B-3-P4a_2022050420220504.pdfUtah State Legislature
  31. 31.Oregon Revised Statutes §§ 31.260–31.278 — Early Discussion and Resolution of adverse health care incidents. https://www.oregonlegislature.gov/bills_laws/ors/ors031.htmlOregon Legislative Assembly
  32. 32.The Patient Safety and Quality Improvement Act of 2005 (Pub. L. 109-41; 42 U.S.C. §§ 299b-21 to 299b-26) and the Patient Safety Rule, 42 CFR Part 3 — privilege and confidentiality of patient safety work product — AHRQ PSO Program FAQ, “What are the privacy and confidentiality protections for PSWP?”. https://pso.ahrq.gov/faq/privacy-and-confidentiality-protectionsAHRQ Patient Safety Organization Program
  33. 33.42 CFR § 482.13 — Condition of participation: Patient's rights, including the grievance process at § 482.13(a)(2). https://www.law.cornell.edu/cfr/text/42/482.13Legal Information Institute, Cornell Law School
  34. 34.State Operations Manual, Appendix A — Survey Protocol, Regulations and Interpretive Guidelines for Hospitals (Rev. 238, issued March 20, 2026), tags A-0118 and A-0122 on patient grievances. https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/som107ap_a_hospitals.pdfCenters for Medicare & Medicaid Services
  35. 35.Never Events Fact Sheet (last revised April 1, 2026) — the five commitments adopted in 2007, the four added in 2017, and the stated rationale for each. https://ratings.leapfroggroup.org/sites/default/files/2026-04/2026%20Never%20Events%20Fact%20Sheet.pdfThe Leapfrog Group
  36. 36.SOPS Hospital Survey Database — the 2024 database report covering 445 U.S. hospitals and more than 280,000 staff and providers, with AHRQ's statement that the database is not representative of all U.S. hospitals. https://www.ahrq.gov/sops/databases/hospital/index.htmlAgency for Healthcare Research and Quality
  37. 37.Mello MM, Kachalia A, Roche S, et al., “Outcomes In Two Massachusetts Hospital Systems Give Reason For Optimism About Communication-And-Resolution Programs,” Health Affairs 36(10):1795–1803 (2017). https://pubmed.ncbi.nlm.nih.gov/28971925/Health Affairs, via PubMed
  38. 38.Nevada Revised Statutes § 439.855 — notice to each patient involved in a sentinel event not later than 7 days after discovery. https://www.leg.state.nv.us/nrs/nrs-439.htmlNevada Legislature
  39. 39.Patient Safety Act, P.L. 2004, c. 9, N.J.S.A. 26:2H-12.25(d), as enacted — informing the patient of a serious preventable adverse event no later than the end of the episode of care. https://pub.njleg.state.nj.us/bills/2004/PL04/9_.HTMNew Jersey Legislature
  40. 40.105 CMR 130.332 — Serious reportable events: report and disclosure to the patient within seven calendar days (B), and the prohibition on charging for a preventable SRE resulting from a system failure (D). https://www.law.cornell.edu/regulations/massachusetts/105-CMR-130-332Legal Information Institute, Cornell Law School
  41. 41.Florida Statutes § 395.1051 — duty to notify patients in person about adverse incidents that result in serious harm. http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&URL=0300-0399/0395/Sections/0395.1051.htmlFlorida Legislature
  42. 42.Massachusetts General Laws ch. 111, § 51H — reporting of serious reportable events; charges or reimbursement for resulting services prohibited. https://malegislature.gov/Laws/GeneralLaws/PartI/TitleXVI/Chapter111/Section51HThe General Court of the Commonwealth of Massachusetts
  43. 43.Medicare National Coverage Determinations Manual, Chapter 1, Part 2, §§ 140.6–140.8 — wrong surgical or other invasive procedure, wrong body part, and wrong patient (effective January 15, 2009). https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/ncd103c1_Part2.pdfCenters for Medicare & Medicaid Services
  44. 44.Medicare Claims Processing Transmittal 1819, Change Request 6405 (September 25, 2009) — claims for the wrong-surgery national coverage determinations, including beneficiary liability. https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1819CP.pdfCenters for Medicare & Medicaid Services
  45. 45.42 CFR § 447.26 — Prohibition on payment for provider-preventable conditions (Medicaid). https://www.law.cornell.edu/cfr/text/42/447.26Legal Information Institute, Cornell Law School
  46. 46.National Performance Goals, Hospital Program, effective January 2026 — NPG.02.03.01, EP 5 (comprehensive systematic analysis of sentinel events) and EP 6 (support systems for staff involved in an adverse or sentinel event). https://digitalassets.jointcommission.org/api/public/content/9ca80055182b4274842a5780a94f2c82The Joint Commission

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