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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/129-ss-blank-lfd.docx
April 01, 2025 - Develop interventions for each important contributing factor and rate each intervention for its ability … Rate each contributing factor on its importance to this and future events. … Develop an intervention for each important contributing factor identified. … and weak interventions and then rate each intervention on its ability to mitigate the contributing factor … Interventions To Reduce the Risk of the Defect
Ability To Mitigate the Contributing Factor, 1 (Low to
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psnet.ahrq.gov/node/40831/psn-pdf
October 05, 2011 - 'Alarm fatigue’ a factor in 2nd death.
October 5, 2011
Kowalczyk L. Boston Globe. …
https://psnet.ahrq.gov/issue/alarm-fatigue-factor-2nd-death
Reporting on a patient death involving … https://psnet.ahrq.gov/issue/alarm-fatigue-factor-2nd-death
https://psnet.ahrq.gov/issue/patient-alarms-often-unheard-unheeded
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psnet.ahrq.gov/node/39874/psn-pdf
September 29, 2010 - Medical malpractice: the fear factor.
September 29, 2010
Robeznieks A. Modern Physician. … https://psnet.ahrq.gov/issue/medical-malpractice-fear-factor
This piece discusses evidence collected … https://psnet.ahrq.gov/issue/medical-malpractice-fear-factor
https://psnet.ahrq.gov/issue/medical-malpractice-and-errors
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module5/module5_pressureinjury-msmt_slides.pptx
June 02, 2025 - risk assessment within
24 hours of admission
Performance of care planning that addresses each risk factor … identified during risk factor assessment
36
Performance Review of Comprehensive
Skin Assessment … Tool 5C
37
Risk Factor Assessment Within 24 Hours
Use the Braden Pressure Injury Scale (or the one … 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/research/findings/final-reports/ssi/ssi3.html
April 01, 2018 - Master Risk Factor List with Final Bolded
Appendix N. Surgeon Focus Group Guide
Appendix O. … Keywords used for the search included: SSI, surgical site infection, surgical risk factor, risk factor … From that search, 24 additional potential risk factors were included in the Master Risk Factor table … The data values for each risk factor, their description, and type were agreed upon via conference calls … While herniorrhaphy was included as a risk factor during the univariate analysis that included surgery
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www.uspreventiveservicestaskforce.org/uspstf/behavioral-counseling-interventions-evidence-based-approach-figure-1
November 01, 2013 - to three other boxes: "Sustained Health Behavior Change," "Intermediate Health Improvement or Risk Factor … "Behavioral Counseling Interventions in Clinical Care" to "Intermediate Health Improvement or Risk Factor … linked by a dotted line to the next immediate box to its right, "Intermediate Health Improvement or Risk Factor … Is risk factor reduction or measured health improvement associated with reduced morbidity and/or mortality … Are behavioral counseling interventions in clinical care directly related to improved health or risk factor
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psnet.ahrq.gov/issue/inter-hospital-transfer-independent-risk-factor-hospital-associated-infection
August 26, 2011 - Study
Inter-hospital transfer is an independent risk factor for hospital-associated … Inter-hospital transfer is an independent risk factor for hospital-associated infection. … Inter-hospital transfer is an independent risk factor for hospital-associated infection.
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apg.html
August 01, 2022 - Event Investigation and Analysis Guide: Appendix G
Data Measurement Plan
Contributing Factor
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www.ahrq.gov/research/findings/final-reports/ssi/ssiapu.html
September 01, 2018 - Master Risk Factor List with Final Bolded
Appendix N. Surgeon Focus Group Guide
Appendix O. … , risk factor, surgical wound, surgical infection. … Each potential risk factor clinically reviewed and categorized as modifiable or nonmodifiable. … Next most common risk factor was history of MRSA (identified 7 times) followed by postop hematocrit ( … Need to distinguish manifestation of SSI vs risk factor.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/ontimefallpxsamplereports.docx
June 02, 2025 - The presence of at least one high-risk change in condition factor indicates high risk of a fall. … The presence of at least one change in status that is a contributing fall risk factor is important but … A resident is considered at high risk of falls if there is at least one new contributing risk factor … For each risk factor, a percentage is calculated to indicate how frequently each risk factor was associated … Because each fall may have more than one risk factor associated with it, the total of the risk factor
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psnet.ahrq.gov/node/43661/psn-pdf
November 05, 2014 - The human factor.
November 5, 2014
Langewiesche W. … https://psnet.ahrq.gov/issue/human-factor
This magazine article provides a breakdown of the failures … https://psnet.ahrq.gov/issue/human-factor
https://psnet.ahrq.gov/issue/all-can-be-lost-risk-putting-our-knowledge-hands-machines
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psnet.ahrq.gov/issue/human-factor-improve-patients-safety-hospitals-urged-adjust-how-staff-use-new-technology
April 22, 2016 - Newspaper/Magazine Article
The human factor. … The human factor. … The human factor.
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www.ahrq.gov/research/findings/final-reports/ssi/ssiapa.html
April 01, 2018 - Master Risk Factor List with Final Bolded
Appendix N. Surgeon Focus Group Guide
Appendix O. … Task 3
Progress update of risk factor organization review. … Task 3
Review if master risk factor list. … Task 3
Review if master risk factor list
Master risk factor list is complete. … Development of table to indicate where each system had the data for each risk factor.
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/reports.html
November 01, 2017 - The presence of at least one high-risk change in condition factor indicates high risk of a fall. … A resident is considered at high risk of falls if there is at least one new contributing risk factor … For each risk factor, a percentage is calculated to indicate how frequently each risk factor was associated … Because each fall may have more than one risk factor associated with it, the total of the risk factor … Purpose
The purpose of the report is to display facility patterns by contextual factor.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/vtguide/umich-slides.ppt
May 20, 2012 - VTE risk factor reorganization based on Clinical Advisory Group feedback (by risk factor category rather
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www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/spotlights/spotlight-patterns-fall-interventions.pdf
September 01, 2023 - Common interventions in place among falls from patients with sensory impairment risk
factor vs. patients … without sensory impairment risk factor ................................................... 13
A3. … Sensory impairment is the second most commonly cited patient risk factor for falls in the
NPSD. … There is little variation in common interventions between the subgroup of patients with a risk factor … without sensory impairment risk factor
A3.
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psnet.ahrq.gov/issue/adverse-drug-reactions-and-therapeutic-errors-older-adults-hazard-factor-analysis-poison
September 09, 2013 - Study
Adverse drug reactions and therapeutic errors in older adults: a hazard factor … Adverse drug reactions and therapeutic errors in older adults: a hazard factor analysis of poison center … Adverse drug reactions and therapeutic errors in older adults: a hazard factor analysis of poison center
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digital.ahrq.gov/principal-investigator/munson-sean
January 01, 2023 - Proc SIGCHI Conf Hum Factor Comput Syst 2017 May 2;2017:6876-88. PMID: 28516176. … Proc SIGCHI Conf Hum Factor Comput Syst 2016 May 7;2016:5658-64. PMID: 28804795. … Proc SIGCHI Conf Hum Factor Comput Syst 2016 May;2016:5632-44. PMID: 28503679. … Proc SIGCHI Conf Hum Factor Comput Syst 2016 May;2016:1109-13. PMID: 28503678.
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/recombinant-factor-viia_disposition-comments.pdf
June 01, 2010 - Comparative Effectiveness of Recombinant Factor VIIa for Off-Label Indications vs. Usual Care. … Thromboembolic
adverse events after use of recombinant human coagulation
factor VIIa. … Treatment of
traumatic bleeding with recombinant factor VIIa. … Recombinant
activated coagulation factor VII and bleeding trauma patients. … " or "Factor IX" or "Factor VIII" as if they were proper nouns,
which they are not.
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digital.ahrq.gov/sites/default/files/docs/citation/AppendixC_HIT_Hazard_Manager_Beta_Test.pdf
June 16, 2021 - A B C D E F
Table: Causation Pages – Results of Descriptive Analysis
7
Causation Category Factor … (n=9)
Table: Causation Pages – Results of Descriptive Analysis
8
Causation Category Factor … (n=11)
Table: Causation Pages – Results of Descriptive Analysis
10
Causation Category Factor … (n=79)
Table: Causation Pages – Results of Descriptive Analysis
11
Causation Category Factor … 58%
73% 75%
30%
72%
0%
20%
40%
60%
80%
100%
Percent of Hazards with a Usability Factor