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pbrn.ahrq.gov/news/events/ahrq-research-summit-diagnostic-safety.html
April 01, 2019 - Organizational Factors— Chapter 6: Organizational Characteristics, the Physical Environment, and the
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pbrn.ahrq.gov/news/newsletters/e-newsletter/891.html
November 01, 2023 - include:
Understanding and Improving Diagnostic Safety in Ambulatory Care: Incidence and Contributing Factors … Generalizability and portability of natural language processing system to extract individual social risk factors
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pbrn.ahrq.gov/cahps/quality-improvement/improvement-guide/6-strategies-for-improving/health-promotion-education/strategy6j-support-self-care.html
March 01, 2020 - Reduce the need for hospitalizations
These studies did not detect short-term improvement in other factors … such as pain and psychological well-being, but there is evidence of significant improvements of these factors
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pbrn.ahrq.gov/research/findings/nhqrdr/index.html
March 01, 2024 - and programs aiming to reduce health disparities by exploring the relationship between socioeconomic factors
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pbrn.ahrq.gov/patient-safety/reports/advancing/index.html
July 01, 2022 - patient safety infrastructure, the Agency began its work to gain a better understanding of the systemic factors … Researchers studied the best ways to identify and report on these factors and examined the impact that … Investigate clinical informatics along with costs, feasibility, and usability factors. … topics including analyzing root causes, analyzing health care failure modes and effects, applying human factors … Determine scope, risk factors, and control measures for hospital-acquired, community-onset MRSA infections
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pbrn.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/curriculum/teamstepps-module-3-slides.pptx
February 28, 2022 - goals.
7
7
Situation Awareness Small
Group Discussion
Situation Monitoring
Goal:
Identify factors … Process:
In your group, compile a list of factors that affect situation awareness in your team.
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pbrn.ahrq.gov/topics/central-line-associated-bloodstream-infections-clabsi.html
with participants in AHRQ's CUSP national implementation project, describes practices and "success factors
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pbrn.ahrq.gov/healthsystemsresearch/hspc-research-study/summary.html
July 01, 2021 - Synthesis; CMS on Cost and Utilization and on Financing of Care; CDC on Prevention; and ACL on Social Factors … Social Factors
Role of health care systems in addressing social determinants of health. a
Effect … of social factors on demand for health care services. a
Personal Preferences and Behaviors
Integrating … outcomes. a
Effects of health care payment models on different patient populations. a
Social Factors … Role of health care systems in addressing social determinants of health. a
Effect of social factors
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/grandrounds/mod01-grand-rounds-slides.pdf
April 01, 2016 - focus of the event investigation
is process improvement and conducting the investigation with a human factors … ■ The team is interdisciplinary and has human factors expertise. … of the CANDOR process of investigating the root cause of how
an error occurred, including the human factors … The CANDOR process recommends that organizations take a systems approach
with human factors integrated … Slide 24
Say:
Human factors engineering is about redesigning the system within which
humans work,
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4g_combo_psi10-postopmetaderangement-bestpractices.pdf
May 20, 2016 - Manage Prevention Strategies
for Postoperative Patients
Avoid risk factors for acute renal failure … dietary self-management skills.5
• Carefully monitor and set up protocols to address the following risk factors … Risk factors for acute postoperative renal failure in
thoracic or thoracoabdominal aortic surgery: A
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4y_combo_nqi03-bsi-bestpractices.pdf
May 17, 2016 - Identify the risk factors that are most common among neonates
for bloodstream infection and screen … Recommended Practice: Assess neonatal patients for risk factors
• Assess all neonatal NICU patients … Risk factors for neonatal BSI include2-5:
○ Gestational age at birth <32 weeks or birth weight <1,500 … to best practices
specific to the age of the child, type of central line, and other patient-related factors … Care
Introduction: Essential First Steps
Recommended Practice: Assess neonatal patients for risk factors
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pbrn.ahrq.gov/teamstepps-program/curriculum/situation/teach/two-day.html
February 01, 2024 - Using Slide 9, “Conditions That Maximize Situation Awareness,” ask the groups to compare their lists of factors … Using Slide 17, “Environment,” ask participants to look at this list and identify other environmental factors … Explain that encouraging people to acknowledge when one or more of these factors (e.g., illness, medications
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pbrn.ahrq.gov/cahps/bibliography/index.html
March 05, 2024 - self-reported general and mental health status among colorectal cancer survivors: impact of sociodemographic factors … self-reported general and mental health status among colorectal cancer survivors: impact of sociodemographic factors … older breast cancer survivors by clinical cancer characteristics, race/ethnicity, and socioeconomic factors
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/psml-planning-grants-final-report.pdf
May 01, 2016 - In the assessment of the factors involved in pregnancy-associated and pregnancy-related deaths,
the … top three individual factors identified were chronic medical conditions, substance abuse, and
delay … retaining of old prescriptions,
and problems with access to medications) and health system factors … In the assessment of the factors involved in pregnancy-associated and pregnancy-related deaths,
the … top three individual factors identified were chronic medical conditions, substance abuse, and
A-25
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pbrn.ahrq.gov/sites/default/files/wysiwyg/topics/defining-diagnostic-error-a-scoping-review.pdf
April 27, 2022 - Diagnosis also involves uncertainty and evolves over
time.8 All of these factors make diagnostic errors … The missed
opportunity may result from cognitive and/or system factors or may be attributable to more … blatant factors, such as lapses
in accountability or clear evidence of liability or negligence.
2. … Factors and impact of physicians’
diagnostic errors in malpractice claims in Japan. … Contributing factors for pediatric
ambulatory diagnostic process errors: project RedDE.
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pbrn.ahrq.gov/evidencenow/projects/heart-health/evidence/cholesterol.html
March 01, 2021 - 75 years with no history of cardiovascular disease (CVD) and for those who have one or more CVD risk factors
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/pressure_ulcer_prevention/module5/module5_pu_measurement.docx
January 01, 2016 - Slide 40
SAY: For a risk factor assessment to make a difference, all the risk factors identified in … on the part of staff and a tailored approach to each patient based on the individual patient’s risk factors
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pbrn.ahrq.gov/sops/news/previous-announcements.html
November 01, 2023 - Healthcare organizations should consider a variety of factors when deciding to administer a SOPS survey … Each organization will need to weigh these factors to determine when to assess patient safety culture
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pbrn.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/community-pharmacy/pharmacy-resources.pdf
May 01, 2023 - nomenclature
• Drug standardization, storage, and distribution
• Use of devices
• Environmental factors … Distractions and Interruptions
https://safetyiq.academy/reducing-distractions-and-interruptions/human-factors … describes eight ways to reduce interruptions or improve lines of defense in
pharmacies using human factors … /#_ftnref1
https://safetyiq.academy/reducing-distractions-and-interruptions/human-factors-engineering … The primer also identifies known risk factors for ADEs, including health literacy, patient
characteristics
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pbrn.ahrq.gov/evidencenow/projects/heart-health/about/cooperatives/north-carolina.html
March 01, 2021 - almost one-third of deaths are caused by CVD (the CVD mortality rate is 251 per 100,000). 2 CVD risk factors … Primary Care Practices Appears Lower Than Expected: An Initial Snap Shot from Evidence NOW [SGIM, 2017]
Factors