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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/cusp-icu-notes.docx
April 01, 2022 - The 5 Whys technique helps understand why one contributing factor led to another contributing factor.
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www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/results/research/cooperative-context-external.pdf
January 01, 2016 - Coop_Context_Info_Assessment
COOPERATIVE CONTEXT ASSESSMENT INFORMATION
Round 2: External Support
What is the importance of context?
Cooperatives’ initiatives are taking place in different settings, and each cooperative has a variety of different partners and
stakeholders involved. Understanding these project…
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www.ahrq.gov/chsp/about-chsp/centers-of-excellence/dartmouth.html
August 01, 2017 - Dartmouth College Center of Excellence
Overview
Dartmouth College’s Center of Excellence is collaborating with the University of California at Berkeley, Harvard University, and the High Value Healthcare Collaborative to study the use of evidence-based innovations in health systems and their impact on health c…
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www.ahrq.gov/funding/grantee-profiles/grtprofile-fairbanks.html
December 01, 2023 - Grantee Profile
Improving Patient Safety in Healthcare
Rollin J. Fairbanks, M.D., M.S.
Senior Vice President and Chief Quality and Safety Officer
MedStar Health
Rollin J. Fairbanks,
M.D., M.S.
“With support from AHRQ, I’ve been able to influence the way that healthcare leaders think about s…
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruhealing/guide.html
December 01, 2017 - dietitian is an important member of a pressure ulcer healing team because declining nutrition is a key risk factor … Some identify a profile of risk factors; others focus on a particular risk factor. … that may help in more general ways to improve preventive practices by focusing on a particular risk factor
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www.ahrq.gov/sites/default/files/2024-12/karsh-report.pdf
January 01, 2024 - important type of safety data: hazards. 19-23 “Hazard” is
a safety term that that is analogous to “risk factor … that increases the probability of errors or of patient/
employee injury and is analogous to “risk factor … were given the following definition of a hazard:
“Hazard” is a safety term that is analogous to “risk factor … For
example, smoking is a risk factor for lung cancer; it won’t necessarily lead
to it, but it could … Fatigue
may be a factor. (actually in all!)
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www.ahrq.gov/sites/default/files/wysiwyg/hai/abate/faqs/faq-iodophor.pdf
March 01, 2022 - Because having MRSA in the nose is a
known risk factor for later infection, your hospital has decided
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www.ahrq.gov/sites/default/files/wysiwyg/hai/abate/faqs/faq-mupirocin.pdf
March 01, 2022 - Because having MRSA in the nose is a
known risk factor for later infection, our hospital has decided
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/factraining.html
September 01, 2017 - dietitian is an important member of a pressure ulcer team because declining nutrition is a key risk factor … Some identify a profile of risk factors; others focus on a particular risk factor. … that may help in more general ways to improve preventive practices by focusing on a particular risk factor
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www.ahrq.gov/sites/default/files/2024-10/sills-report.pdf
January 01, 2024 - Because most recent studies of crowding use quality measures as the basis for comparison,7 a
factor … the timeliness and effectiveness of ED asthma care and can raise the risk of
lower-quality care by a factor … of 3.8 for 1-hour steroid administration and a factor of 1.2 for
receipt of indicated asthma score, … the timeliness and effectiveness of ED asthma care and can
raise the risk of lower-quality care by a factor … of 3.8 for 1-hour steroid administration and a
factor of 1.2 for receipt of indicated asthma score,
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www.ahrq.gov/evidencenow/projects/heart-health/about/cooperatives/midwest.html
March 01, 2021 - SMART: Behavioral Risk Factor Surveillance System City and County Data. 2013.
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www.ahrq.gov/sites/default/files/wysiwyg/cpi/about/how-well-do-you-know-ahrq-quizzes.pdf
September 01, 2024 - Too few support stah members was not seen as a major factor
causing physician burnout, especially compared
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www.ahrq.gov/es/patient-safety/settings/hospital/vtguide/guide7.html
May 01, 2016 - mobility is common in the inpatient setting, and immobility is a well-established and powerful risk factor … In fact, relative immobility in the hospital is a risk factor for delirium, decubiti, ileus, deconditioning
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www.ahrq.gov/patient-safety/settings/hospital/vtguide/guide7.html
May 01, 2016 - mobility is common in the inpatient setting, and immobility is a well-established and powerful risk factor … In fact, relative immobility in the hospital is a risk factor for delirium, decubiti, ileus, deconditioning
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Harder.pdf
May 19, 2003 - Improving the Safety of Heparin Administration by Implementing a Human Factors Process Analysis
323
Improving the Safety of Heparin
Administration by Implementing a
Human Factors Process Analysis
Kathleen A. Harder, John R. Bloomfield,
Sue E. Sendelbach, Michele F. Shepherd, Pam S. Rush,
Jamie S. Sinclair,…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4k_combo_psi14-dehiscence-bestpractices.pdf
May 20, 2016 - 2008 the Centers for
Medicaid and Medicare Services (CMS) identified surgical site infections (a risk factor
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module5/mod5-case-scenarios.pdf
April 01, 2016 - The patient’s physical make-up was considered to be a causative factor.
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www.ahrq.gov/hai/tools/mvp/modules/cusp/learn-from-defects-slides.html
February 01, 2017 - Why 1—Why did this contributing factor occur?
Why 2—Why did “Why 1” occur?
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Hurley_55.pdf
March 07, 2008 - cause of the
patient’s INR result
variation, since the
measurement system can be
a significant factor … The third variable in the INR equation is a normalizing factor, called the mean normal
prothrombin time … This is the factor used to standardize labs to one
another:
INR = (Patient pro time/MNPT)ISI
For
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www.ahrq.gov/hai/cusp/modules/understand/alt-text.html
July 01, 2018 - Factors Can Predict Performance
Examples of the Impact of System-Level Factors
System Factor