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psnet.ahrq.gov/node/37980/psn-pdf
October 28, 2009 - Double checking medicines: defence against error or
contributory factor? … Double checking medicines: defence against error or contributory factor? … https://psnet.ahrq.gov/issue/double-checking-medicines-defence-against-error-or-contributory-factor … https://psnet.ahrq.gov/issue/double-checking-medicines-defence-against-error-or-contributory-factor
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www.ahrq.gov/research/findings/final-reports/ssi/ssiapq.html
April 01, 2018 - Master Risk Factor List with Final Bolded
Appendix N. Surgeon Focus Group Guide
Appendix O. … current risk adjustment models are inappropriate because of improperly accounting for nonmodifiable factor … Factors, Risks, and Rates
The specific definition of a factor is important. … Consider conducting an intervention on one or more risk factor variables based on risk level, instead … drawing attention to measurement and tracking of risk factors; and intervening on one or more risk factor
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psnet.ahrq.gov/issue/psychometric-properties-ahrq-community-pharmacy-survey-patient-safety-culture-factor-analysis
February 07, 2018 - Psychometric properties of the AHRQ Community Pharmacy Survey on Patient Safety Culture: a factor … Psychometric properties of the AHRQ Community Pharmacy Survey on Patient Safety Culture: a factor analysis … Psychometric properties of the AHRQ Community Pharmacy Survey on Patient Safety Culture: a factor analysis … May 10, 2017
Operationalizing occupational fatigue in pharmacists: an exploratory factor
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www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/api.html
August 01, 2022 - Causal factor: the suspected or confirmed factors that caused the adverse event. … Labeling one or even several of these factors as "causes" may place undue emphasis on a single specific factor … Contributing factor: additional elements that contributed to the adverse event, many of which are outside … In a systems approach, root cause is referred to as contributing factor.
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www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/ssi/ssiapu.pptx
September 18, 2011 - , risk factor, surgical wound, surgical infection. … 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 … Next most common risk factor was history of MRSA (identified 7 times) followed by postop hematocrit ( … While herniorrhaphy was included as a risk factor during the univariate analysis that included surgery
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psnet.ahrq.gov/node/35356/psn-pdf
May 27, 2011 - Computerized physician order entry, a factor in
medication errors: descriptive analysis of events in … JCOM. 2(8):407-412
https://psnet.ahrq.gov/issue/computerized-physician-order-entry-factor-medication-errors-descriptive … https://psnet.ahrq.gov/issue/computerized-physician-order-entry-factor-medication-errors-descriptive-analysis-events … https://psnet.ahrq.gov/issue/computerized-physician-order-entry-factor-medication-errors-descriptive-analysis-events
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psnet.ahrq.gov/issue/post-hospital-medication-discrepancies-home-risk-factor-90-day-return-emergency-department
March 18, 2020 - Study
Post-hospital medication discrepancies at home: risk factor for 90-day return … Post-Hospital Medication Discrepancies at Home: Risk Factor for 90-Day Return to Emergency Department … Post-Hospital Medication Discrepancies at Home: Risk Factor for 90-Day Return to Emergency Department
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psnet.ahrq.gov/node/40800/psn-pdf
December 09, 2014 - 'Tempos' management in primary care: a key factor for
classifying adverse events, and improving quality … 'Tempos' management in primary care: a key factor for classifying adverse events,
and improving quality … https://psnet.ahrq.gov/issue/tempos-management-primary-care-key-factor-classifying-adverse-events-and … https://psnet.ahrq.gov/issue/tempos-management-primary-care-key-factor-classifying-adverse-events-and-improving-quality … https://psnet.ahrq.gov/issue/tempos-management-primary-care-key-factor-classifying-adverse-events-and-improving-quality
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psnet.ahrq.gov/node/45634/psn-pdf
January 11, 2017 - Operating room traffic as a modifiable risk factor for
surgical site infection. … Operating Room Traffic as a Modifiable Risk Factor for
Surgical Site Infection. … https://psnet.ahrq.gov/issue/operating-room-traffic-modifiable-risk-factor-surgical-site-infection
Surgical … https://psnet.ahrq.gov/issue/operating-room-traffic-modifiable-risk-factor-surgical-site-infection
https
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www.ahrq.gov/hai/cusp/toolkit/learn-defects.html
December 01, 2012 - Develop interventions for each important contributing factor, and rate each intervention for its ability … Please read each contributing factor and evaluate whether it was involved. … Was the provider's physical or mental health a factor? … Rate each contributing factor on its importance to this and future events. … Develop an intervention for each important contributing factor identified.
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psnet.ahrq.gov/issue/use-safety-climate-questionnaire-uk-health-care-factor-structure-reliability-and-usability
June 15, 2011 - Study
Use of a safety climate questionnaire in UK health care: factor structure, … Use of a safety climate questionnaire in UK health care: factor structure, reliability and usability. … Use of a safety climate questionnaire in UK health care: factor structure, reliability and usability. … Opportunities for improvement in nursing homes: variance of six patient safety climate factor
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/COVID-19-pharmaceutical-treatments-rapid-review.pdf
March 01, 2024 - RR = 0.98;
CI: 0.06, 15.05
Neurosensory
alteration: 0/40, 1/39
RR = 0.33; CI: 0.01,
7.95
Risk factor … units
Titer: high titer
Timing: 9 days
Control: Placebo
Cutoff: 45 days or less: 28
Risk factor … Analysis
Risk of Bias (ROB)
RR = 2.96; CI: 0.12,
72.49
Risk factor analysis:
NR
Pub … Analysis
Risk of Bias (ROB)
RR = 3.03; CI: 0.12,
74.27
Risk factor analysis:
NR
Pub … Analysis
Risk of Bias (ROB)
RR = 3.02; CI: 0.12,
73.90
Risk factor analysis:
NR
Pub
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psnet.ahrq.gov/issue/effectiveness-improving-healthcare-teams-human-factor-skills-using-simulation-based-training
June 08, 2022 - Review
The effectiveness of improving healthcare teams' human factor skills using … The effectiveness of improving healthcare teams’ human factor skills using simulation-based training: … The effectiveness of improving healthcare teams’ human factor skills using simulation-based training:
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digital.ahrq.gov/ahrq-funded-projects/feedback-treatment-intensification-data-reduce-cardiovascular-disease-risk/annual-summary/2010
January 01, 2010 - Such measures could also be more useful than reports of risk-factor control because the actions needed … need for treatment intensification in patients with poor control of CVD risk factors improves risk-factor … the PHASE population management database and the same software but received information only on risk-factor … Secondary endpoints included proportions in control for each risk factor; treatment intensification and … risk-factor improvements in patient subgroups defined by prior adherence to prescribed medications;
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www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-medication-chartbook-2024.pdf
January 01, 2024 - reported: 9,215 (10.0%)
reported Human Factor, 4,345 (4.7%) reported Communication, and 2,249 (2.4% … For all 21,345 Medication or Other Substance
Incorrect Dose Incidents where CONTRIBUTING FACTOR(S) … FOR EVENT was reported,
2,502 (11.7%) reported a contributing factor to be Human Factors, 876 (4.1% … (S) FOR EVENT was reported, 3,711 (12.0%) indicated Human
Factors as a contributing factor. … question: “What factor(s) contributed to the event?”
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www.ahrq.gov/sites/default/files/2024-07/peters-report.pdf
January 01, 2024 - In particular, past results lead us to expect two factors: one factor
related to the dreadedness of … the error and a second factor related to the patient's ability to
prevent the error. … In a factor analysis of perceived
risk characteristics of medical errors, two factors emerged. … Factor 1, labeled Dread, was
composed of blame, harmfulness, hospital/staff preventability, patient … Factor 2 ,labeled Preventability, is patient oriented; patients can observe and prevent the
error.
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digital.ahrq.gov/sites/default/files/docs/page/2006WakefieldHalbeslebenWard_051311comp.pdf
June 16, 2021 - used for following analyses included 19 items
in Section I and 17 items in Section II
Section I Factor … Analysis Results
Confirmatory factor analysis supported five-
factor structure for 17 items in Section … Analysis Results
Confirmatory factor analysis supported two-
factor structures
Proposed factors … Section II
Section II:�Implementation Strategy & Quality
Method
Results: Item Analysis
Section I Factor … Results: Pre/Post Comparison
Results: Section I Pre/Post Experience with Technology
Section II Factor
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psnet.ahrq.gov/issue/operating-room-traffic-modifiable-risk-factor-surgical-site-infection
April 24, 2018 - Study
Operating room traffic as a modifiable risk factor for surgical site infection … Operating Room Traffic as a Modifiable Risk Factor for Surgical Site Infection. … Operating Room Traffic as a Modifiable Risk Factor for Surgical Site Infection.
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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