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  1. talkingquality.ahrq.gov/research/findings/final-reports/index.html?page=8
    September 01, 2005 - Medication Safety (73) Communication and Teamwork (29) Patient Safety Tools (19) Human Factors … Implementation (7) Education and Training (6) Emergency Care (5) Human and Environmental Factors … These topics include human factors approaches to improve patient safety, patient safety measure development … 3 4 5 6 7 8 9 Real-Time Assessment of Risk Factors
  2. talkingquality.ahrq.gov/practiceimprovement/delivery-initiative/mccannon/index.html
    December 01, 2020 - Slide 11 A Framework A graphic depiction of the framework showing the six factors that influence … The six factors are: current environment, foundation, framing, nature, structural context and method. … Slide 20 A Framework A graphic depiction of the framework showing the six factors that influence … The six factors are: current environment, foundation, framing, nature, structural context and method.
  3. talkingquality.ahrq.gov/sites/default/files/wysiwyg/topics/managing-interruptions-improve-diagnostic-decisionmaking.pdf
    December 29, 2022 - Diagnostic Decision-Making JGIM Accordingly, we use these strategies to propose specific re- Other Factors … There are other factors that disrupt decision-making that are not included in our model such as cognitive … We also do not account for interactions between interruptions and these factors, such as when trying … For example, one review concluded that there are three main disruptive factors: duration of the inter … It is challenging to disentangle all the factors involved in diagnostic decision-making because it is
  4. talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module5/module5_slides_fallprev.pptx
    December 03, 2012 - Ensure that known risk factors for falls are assessed. … Page 78 ‹#› Care Planning Assessment All risk factors identified on the fall risk factor assessment … Critical thinking by staff Tailored approach to each patient, based on the patient’s risk factors Ensure
  5. talkingquality.ahrq.gov/patient-safety/resources/learning-lab/acute-care-threats-long-desc.html
    February 01, 2024 - Engage stakeholders using mixed methods and systems engineering approaches to identify factors that contribute … which individual clinicians operate and the contributions of systems, processes, and institutional factors … Four types of factors interact in complex ways to impede diagnostic performance: Organizational (e.g … ICU operational factors, such as admission rates and patient severity of illness, may affect the critical
  6. talkingquality.ahrq.gov/patient-safety/settings/hospital/fall-prevention/workshop/module-5/slides.html
    September 01, 2017 - Ensure that known risk factors for falls are assessed. … Slide 41: Care Planning Assessment All risk factors identified on the fall risk factor assessment … Tailored approach to each patient, based on the patient’s risk factors.
  7. talkingquality.ahrq.gov/sites/default/files/2024-01/joseph3-report.pdf
    January 01, 2024 - Video Observations and Coding Using a human factors framework (Systems Engineering Initiative for Patient … Human Factors. 2018 November; 60(7): 992-1007. https://doi.org/10.1177%2F0018720818780544 10)Mousavi … The influence of traffic, area location, and other factors on operating room microbial load. … Proceedings of the 62nd Annual Meeting of the Human Factors and Ergonomics Society. 2018; Philadelphia … Proceedings of the Human Factors and Ergonomics Society Annual Meeting. 2016; 60(1):608-612. https://
  8. talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module5/module5_fall-prevention.docx
    June 30, 2017 - For example, you may consider adding specific fields for contributing factors to falls (such as high-risk … Instructor’s Note: The hospital may have agreed to use another scale or a simple checklist of risk factors … Slide 41 SAY: For risk factor assessment to make a difference, all risk factors identified on the risk … on the part of staff and a tailored approach to each patient based on the individual patient’s risk factors
  9. Coordination (pdf file)

    talkingquality.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/podcasts/Coordination_of_Care_2012_05_01_Transcript.pdf
    January 01, 2012 - Coordination Understanding the Factors that Affect Care Coordination May 2012  Podcast Speaker … https://www.cahps.ahrq.gov/News-and-Events/Podcasts.aspx Understanding the Factors that Affect Care … It looked http://www.cahps.ahrq.gov/ Understanding the Factors that Affect Care Coordination … http://www.cahps.ahrq.gov/ Understanding the Factors that Affect Care Coordination May 2012  … http://www.cahps.ahrq.gov/ Understanding the Factors that Affect Care Coordination May 2012 
  10. talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module5/module5_tools.docx
    August 03, 2017 - Include in Incident Reports Examples of Information Reason To Collect This Information Reporting factors … Environmental factors Buzzer/bell available within reach before fall Highlight whether there is an … Patient factors Mental state Identify those patients most vulnerable to falls because of sedation,
  11. talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallprevention-training/module2/module2_tools.docx
    November 16, 2011 - * Staff nurses 3G – STRATIFY Scale for Identifying Fall Risk Factors* Staff nurses 3I – Medication … If a process does not exist (for example, there is no process to assess fall risk factors upon admission … All patients should be assessed for fall risk factors at admission, at a change in status, after a fall … Risk factors for falls include: Parkinson’s disease Incontinence Previous history of falls Delirium 11 … Education programs for staff should include the importance of fall prevention, risk factors for falls
  12. talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4n_combo_iqi-mortalityreview-bestpractices.pdf
    May 20, 2016 - further review and prepare selected cases for committee presentation and identify potential causative factors … review results quarterly or biannually as appropriate to determine if there are trends in causative factors … How To Improve Hospital Quality and Safety 6 Tool D.4n o Discussion is focused on causative factors … and preventability3:  Causative factors:  Underlying disease  Treatments and procedures, including … Abdominal Aortic Aneurysm (AAA) Repair Mortality Rate • Using an individualized assessment of risk factors
  13. talkingquality.ahrq.gov/hai/cusp/videos/index.html
    September 01, 2019 - Identifying Contributing Factors What Will You Do to Reduce the Risk of Recurrence? … Nurse Manager as a Mentor and Coach Encourage Professional Development of Staff Work Alignment Spread Factors
  14. talkingquality.ahrq.gov/npsd/data/dashboard/index.html
    October 01, 2023 - and unsafe conditions, then further examines incidents and near misses along with their contributing factors … analyses by age, deeper explorations of common activities prior to fall, and enhanced analyses of risk factors … It also features new incident-specific near misses-specific analyses that examine their contributing factors
  15. talkingquality.ahrq.gov/sites/default/files/wysiwyg/topics/DxSafety-March2019-MeetingNotes.pdf
    March 08, 2019 - • Contributions of human factors to errors that have led to harm. … • AHRQ is interested in multidisciplinary research on the topic (with a heavy emphasis on human factors
  16. talkingquality.ahrq.gov/evidencenow/projects/heart-health/research-results/research/collection.html
    March 01, 2021 - Southwest cooperative conducted interviews with practices to understand the internal and external factors … Internal factors included: practice structure, staffing, priorities, change processes, and methods of … External factors included: concurrent/competing QI projects and health IT infrastructure.  … practices’ motivations and expectations, cooperative organization, and technological and/or geographic factors
  17. talkingquality.ahrq.gov/patient-safety/settings/hospital/candor/modules/notes4.html
    August 01, 2022 - Continuous organizational learning as a result of identification of contributing factors that might help … 30-45 business days after the event, the investigation should allow for the determination of causal factors … By focusing on system processes and factors that facilitated the event, adjustments can be made to minimize … Continuous organizational learning—this allows for identification of contributing factors that led to … Create solutions—once contributing factors and unrelated hazards are identified, sustainable and effective
  18. talkingquality.ahrq.gov/professionals/prevention-chronic-care/improve/coordination/webinar03/logicmodelsl.html
    July 01, 2013 - Contextual factors that may influence the intervention’s ability to produce results. … What contextual factors are likely to affect the process? … Using a logic model to explore how implementation factors related to fidelity relate to fidelity domains … Slide 25 Qualitative Analysis Reveal Implementation Factors Individuals: Program director knowledge
  19. talkingquality.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/education-bundles/infection-prevention/environment-and-equipment/environ-equip-slides.html
    March 01, 2017 - Risk factors Use of common measuring device between residents with indwelling urinary catheters. … Nursing home facility risk factors for infection and hospitalization: importance of registered nurse … turnover, administration, and social factors. … Nursing home facility risk factors for infection and hospitalization: importance of registered nurse … turnover, administration, and social factors.
  20. talkingquality.ahrq.gov/research/findings/studies/index.html?page=480
    January 01, 2024 - Rural/Inner-City Residents (23) Rural Health (133) Screening (456) Sepsis (140) Sex Factors … A study of 264,401 patients admitted to 155 U.S. intensive care units (ICUs) found several factors associated … Brady J AHRQ Author: Henriksen K, Brady J The pursuit of better diagnostic performance: a human factors … The pursuit of better diagnostic performance: a human factors perspective. … Factors affecting adoption and implementation of AHRQ health literacy tools in pharmacies.

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