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  1. ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/roadmap.html
    January 01, 2013 - assistants, facility engineer, hospital employee who enters patient rooms 3.3 Identify important risk factors … Vital Sign Measurement ; Word Version [32.37 KB] Tool 3G, STRATIFY Scale for Identifying Fall Risk Factors … ; Tool 3H, Morse Fall Scale for Identifying Fall Risk Factors ;  Tool 3I, Medication Fall Risk Score … Evaluation Tools ;  Staff nurses, pharmacist, nursing assistants 3.4 Use identified fall risk factors … 6.3 Identify factors need to sustain your fall prevention efforts Tool 6A, Sustainability Tool ;
  2. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/changing-system-slides.pptx
    June 01, 2021 - List factors that may compromise patient safety. … Review list of factors that contributed to the incident. … Check off factors that negatively contributed and positively contributed to the incident. … factors limited the impact of harm 14 Changing the System 14 What Could You Do To Reduce the … Human factors and behavioral safety. Butterworth-Heinemann. 2007; 130–1. Kamoun G, Nicho M.
  3. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/learn-from-defects-slides.pptx
    January 01, 2017 - able to— Describe difference between first-order and second-order problem solving List contributing factors … Contributing factors from all levels of your health care system impact care delivery and, ultimately, … patient outcomes Develop a “system perspective” to see the hidden factors that led to the event List … Work Environment Team Factors Individual Provider Task Factors Patient Characteristics … for Mechanically Ventilated Patients LFD Tool Contributing Factors Learn From Defects ‹#› AHRQ
  4. Fallpxtool3G (doc file)

    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallpxtoolkit/fallpxtool3g.docx
    January 29, 2013 - 3G: STRATIFY Scale for Identifying Fall Risk Factors Background: This tool can be used to identify risk … factors for falls in hospitalized patients. … The total score may be used to predict future falls, but it is more important to identify risk factors … using the scale and then plan care to address those risk factors. … Note that this scale may not capture the risk factors that are most important on your hospital ward,
  5. ce.effectivehealthcare.ahrq.gov/talkingquality/plan/subject.html
    December 01, 2022 - This page reviews the factors that should enter into your decision and suggests some strategies for dealing … Factors to Consider When Deciding Whose Quality to Report To decide who to focus on, start by considering … the five factors below. … The feasibility of measuring and reporting quality depends on multiple factors, including political obstacles
  6. ce.effectivehealthcare.ahrq.gov/funding/grantee-profiles/grtprofile-gurses.html
    November 01, 2023 - Founding Director, Johns Hopkins Center for Health Care Human Factors Armstrong Institute for Patient … engineering principles—thinking of healthcare settings as complex systems in which social and technical factors … Gurses is a globally recognized researcher and educator in applying human factors engineering methods … the Johns Hopkins Armstrong Institute for Patient Safety and Quality’s Center for Health Care Human Factors … Institutions: Johns Hopkins Center for Health Care Human Factors, Armstrong Institute for Patient Safety
  7. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/science-of-safety-facguide.docx
    January 01, 2017 - Slide 5 System Factors Impact Safety SAY: Each level of the health care delivery system matters. … SAY: The following are all factors that impact safety in the health care system: · Institutional factors … , such as the economic and regulatory state of your organization · Hospital factors, such as financial … support · Work environment factors, such as shift patterns and equipment maintenance · Team factors, … , skills, and motivations · Task factors, such as clarity of structure and accuracy of test results ·
  8. ce.effectivehealthcare.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/slides.html
    December 01, 2017 - Intrinsic Fall Risk Factors Slide 5. Intrinsic Fall Risk Factors (continued) Slide 6. … Intrinsic Fall Risk Factors (continued) Slide 7. Extrinsic Fall Risk Factors Slide 8. … Extrinsic Fall Risk Factors (continued) Slide 9. … Extrinsic Fall Risk Factors (continued) Slide 10. Physical Restraints Slide 11. … Intrinsic Fall Risk Factors Effects of Normal Aging Vision - decreased acuity, decreased
  9. ce.effectivehealthcare.ahrq.gov/talkingquality/explain/support/help.html
    November 01, 2018 - Identify the factors they need to consider in making a choice. … that consumers’ decisions about health plans and providers need to take factors beyond quality into … This is one reason to offer information on other factors, such as location, hours, languages spoken, … You can address this point in a discussion of factors to consider. … important to them, but the factors that are most important—what one might call the “deal breakers.
  10. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module3/module3_slides_best-practices.pptx
    June 16, 2017 - How a standardized assessment of fall risk factors should be conducted. … How risk factors should be incorporated into care planning. … Add unit-level risk factors as needed. … Choose a tool for assessing risk factors. … Develop fall prevention care plan based on identified risk factors.
  11. ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/education-dx-outcomes-1.html
    March 01, 2022 - magnitude and importance of the problem, 3 , 4 an increasingly robust understanding has developed of the factors … that lead to diagnostic error, including system, cognitive, and contextual factors. 5 - 7 A promising … While individual, professional, contextual, patient, and health system factors make diagnostic error
  12. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/webinars/webinar4_falls_usingriskassttools.pdf
    January 01, 2013 - measures, care plans, and communication strategies • Links strategies to counteract identified risk factors … That way, staff will not miss any fall risk factors. 11 Basis for Risk Factor Assessment • Validated … – Instead, use assessment tools to identify fall risk factors. … • To plan care that addresses these factors 36 If your hospital has an electronic health record … – Tool 3H: Morse Fall Scale for Identifying Fall Risk Factors – Tool 3I: Medication Fall Risk Scale
  13. ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-3/guide.html
    September 01, 2017 - How a standardized assessment of fall risk factors should be conducted How risk factors should be used … individual patient risk factors. … Add unit-level risk factors as needed. … Additional factors may be added. … risk factors in the care plan.
  14. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/chtoolbx/choosing/choosing.doc
    September 12, 2013 - Think Long Term · Consider All Available Measurement Tools · Think Fewer Measures · Develop a Plan Factors … · Identifies several factors State users may wish to consider when choosing quality measures. … · Reviews selected measures in terms of those factors. … Return to Contents Factors to Consider Many factors are involved in choosing which quality measures … The same factors can be used to assess any of these other measures.
  15. TO (doc file)

    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d8_combo_projectevaluation.docx
    May 25, 2016 - The purpose of the project evaluation is to: Identify factors that contributed to the team’s success. … Identify factors that hindered the team’s success. … List factors that helped and hindered the team’s success. … EVALUATION What factors helped the team succeed? What factors hindered the team’s success? a. a.
  16. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/ontimefallpxsamplereports.pdf
    November 06, 2017 - • Quarterly Summary of Falls Risk Factors by Unit or Facility. … • Monthly Contextual Factors Report. • Postfall Assessment Summary Report. … Sample Quarterly Summary of Falls Risk Factors by Unit On-Time Quarterly Summary of Falls Risk Factors … Report Description The Quarterly Summary of Fall Risk Factors Report is a count of risk factors associated … Sample Monthly Contextual Factors Report by Facility Monthly Contextual Factors Report Date: ___/__
  17. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/module4/mod4-system-focused-event-guide.pdf
    April 01, 2016 - to build consensus around these factors. … These factors are the focus of the solutions meeting. … Visual model (Appendix C) with the list of contributing factors 2. … To determine which contributing factors are most critical, chart the factors evaluating impact and likelihood … The boxes represent different categories of contributing factors.
  18. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/what-we-learned/chipra-factors-influencing-state-reporting.pdf
    July 01, 2016 - What Factors Influence States’ Capacity to Report Children’s Health Care Quality Measures? … , organizational factors, and behavioral factors. … Examining the interplay of these factors across the cases revealed several themes. … Organizational factors History and culture of data collection and use ? - ? ? … Behavioral factors Motivation ? ? ? Demand for measures - ? ­
  19. ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_learn_from_defects_facnotes.docx
    December 01, 2017 - Your institution, hospital factors, departmental factors, work environment, and team factors all contribute … SAY: Keep track of these key factors. … Slide 18 LFD Tool Contributing Factors SAY: For example, what team factors contributed to or minimized … Slide 19 LFD Tool Contributing Factors SAY: Do the same with factors in your local environment. … The goal is to tease out systemic factors that contribute to errors and improve upon those factors.
  20. Fallpxtool3H (doc file)

    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallpxtoolkit/fallpxtool3h.docx
    January 29, 2013 - 3H: Morse Fall Scale for Identifying Fall Risk Factors Background: This tool can be used to identify … risk factors for falls in hospitalized patients. … The total score may be used to predict future falls, but it is more important to identify risk factors … using the scale and then plan care to address those risk factors. … Note that this scale may not capture the risk factors that are most important on your hospital ward,

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