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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/sustainability/sustainability_learn_from_defects.pptx
December 01, 2017 - Pick a contributing factor to address first
Major
Contributor
Minor
Contributor
Occurs
Rarely
Occurs … Pick a contributing factor your team would like to address first. … ASK:
Where would you place a contributing factor on the grid? … SAY:
If a contributing factor is a major reason why the defect occurred, place that factor in the top … This type of contributing factor is a good target for intervention.
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/023-ss-cusp-learning-from-defects-fg.docx
April 01, 2025 - A contributing factor that is a major reason and occurs commonly is a good target for intervention. … Such a factor will likely have a significant impact on risk reduction. … A factor that is not a major reason but commonly occurring may be low-hanging fruit and easier to tackle … A contributing factor that is a major reason but does not occur often offers a potential opportunity … A factor that falls in the category of being a minor reason for the defect and rarely occurs may not
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/ontimefallpxreports-ig.pdf
June 02, 2025 - The presence of at least one
high-risk change in condition factor combined with the presence
of at … The new contributing risk
factor elements represent changes that occurred in a resident’s
clinical … The presence of
at least one change in status that is a contributing fall risk factor
is important … A resident is considered high risk for falls if there is at least one
new contributing risk factor in … The purpose of the report is to display facility trends by
contextual factor.
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www.ahrq.gov/hai/tools/mvp/modules/cusp/learn-from-defects-fac-guide.html
February 01, 2017 - Why did one contributing factor lead to another contributing factor? … And why did the next factor lead to the next? … Say:
When learning from defects, select each contributing factor to assess its impact on causing the … So, prioritize the contributing factors by asking if that contributing factor was major or minor and … how frequently the contributing factor occurs.
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www.ahrq.gov/sites/default/files/2024-07/barnett-report.pdf
January 01, 2024 - CDC 25th Annual Behavioral Risk
Factor Surveillance System (BRFSS) Conference, Orlando (March 18, 2008 … HS 15700
http://www.cdc.gov/pcd/issues/2011/mar/10_0065.htm#Appendix
Adapting the Behavioral Risk Factor … CDC 27th Annual Behavioral Risk Factor
Surveillance System (BRFSS) Conference, San Diego (March 22-23 … CDC 27th Annual Behavioral Risk Factor Surveillance System (BRFSS) Conference, San Diego (March 22-23 … CDC 28th Annual Behavioral Risk Factor Surveillance System (BRFSS) Conference,
Atlanta (March 22, 2011
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/resources/tools/cauti-surveillance/review-form.docx
March 01, 2017 - first page of the document, use the open field text in the column on the right to identify how this factor … _ Antibiotic(s): __________________ Sensitive: Y – N
Contributing Factors
If NO, how could this factor
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/venous-thromboembolism-1.pdf
March 01, 2020 - Researchers found that aspirin, along with factor XI antisense
oligonucleotide (FXI-ASO), ardeparin, … Factor Xa inhibitors were found to have the lowest
incidence of DVT and PE (p<0.01) at 90 days, and … Deep Vein Thrombosis Prophylaxis Orders: Thrombosis Risk Factor Assessment. … Venous Thromboembolism prophylaxis after TKA:
aspirin, warfarin, enoxaparin, or factor xa inhibitors … In
multivariate analysis,
warfarin was an
independent risk
factor for VTE and
mortality in the
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/reportguide.html
November 01, 2017 - The presence of at least one change in status that is a contributing fall risk factor is important but … A resident is considered high risk for falls if there is at least one new contributing risk factor in … For each count of conditions, the percentage of all falls with which that risk factor was associated … For each count of conditions, the percentage of all falls with which that risk factor was associated … The purpose of the report is to display facility trends by contextual factor.
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/quality-improvement/reports-and-case-studies/ExecSummcaseplancustsvce-RAND7607.pdf
July 01, 2007 - o Speed to answer customer calls
o “Total service factor”—portion of calls answered in less than 30 … o Continued to track total service factor, speed to answer customer calls, call
abandonment rate, and … improvements made in 2000 in Member Services telephone
performance, and achieve 90 percent total service factor—the … By the end of 2000, the plan had met all of its operational goals, including total
service factor, call … customer service goals achieved in 2000 were sustained through 2001, with the
exception of total service factor
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/ipe-large-org-webcast-skootsky.pdf
March 01, 2021 - communicated to patients
• ensuring patients are informed of next steps throughout the process.
35
Success Factor … Patient-Physician Communication Workshop
ART (Ambulatory Resource Team)
Investments in Office Staff
Success Factor
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www.ahrq.gov/research/findings/final-reports/stpra/stpraexh3.html
April 01, 2018 - Studies to support or refute information from the site visit estimates
Studies containing risk factor
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www.ahrq.gov/research/findings/final-reports/ssi/ssi5.html
April 01, 2018 - Master Risk Factor List with Final Bolded
Appendix N. Surgeon Focus Group Guide
Appendix O. … combined analysis with only the Intermountain data only identified postop hemoglobin as an additional risk factor … Surgery duration was the only significant risk factor from the previous analysis not included in the … identified only emergency surgery in addition to postop admission while postop admission was the only risk factor
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/learn-from-defects-facguide.docx
January 01, 2017 - Why did one contributing factor lead to another contributing factor? … And why did the next factor lead to the next? … SAY:
When learning from defects, select each contributing factor to assess its impact on causing the … So, prioritize the contributing factors by asking if that contributing factor was major or minor and … how frequently the contributing factor occurs.
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www.ahrq.gov/policymakers/chipra/cpcf-form2.html
December 01, 2013 - electronic data source are not requested at this time, the availability of these resources may be a factor
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www.ahrq.gov/research/findings/final-reports/ssi/ssiaps.html
April 01, 2018 - Master Risk Factor List with Final Bolded
Appendix N. Surgeon Focus Group Guide
Appendix O. … These data suggest that further efforts at risk factor assessment are worthwhile.
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www.ahrq.gov/prevention/guidelines/tobacco/clinicians/presentations/2008update-full/slide135.html
October 01, 2014 - Cardiovascular diseases-NRT is not an independent risk factor for acute myocardial events.
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www.ahrq.gov/patient-safety/settings/hospital/resource/pressureinjury/workshop/guide5.html
October 01, 2017 - Performance of care planning that addresses each risk factor identified during risk factor assessment … Look at the sample protocol for evaluating the performance of pressure injury risk factor assessment … Slide 40
Say: For a risk factor assessment to make a difference, all the risk factors identified … Pressure injury risk factor assessment is performed accurately within 24 hours of admission.
… Care plan addressing every deficit on pressure ulcer risk factor assessment has been developed and is
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module5/module5_pu_measurement.docx
January 01, 2016 - Performance of care planning that addresses each risk factor identified during risk factor assessment … Look at the sample protocol for evaluating the performance of pressure injury risk factor assessment … Slide 40
SAY: For a risk factor assessment to make a difference, all the risk factors identified in … Pressure injury risk factor assessment is performed accurately within 24 hours of admission. … Care plan addressing every deficit on pressure injury risk factor assessment has been developed and is
-
www.ahrq.gov/research/findings/final-reports/ssi/ssiexh47.html
April 01, 2018 - Master Risk Factor List with Final Bolded
Appendix N. Surgeon Focus Group Guide
Appendix O.
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www.ahrq.gov/research/findings/final-reports/ssi/ssiexh51.html
April 01, 2018 - Master Risk Factor List with Final Bolded
Appendix N. Surgeon Focus Group Guide
Appendix O.