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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
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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.
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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
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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
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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
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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.
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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://
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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
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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
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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,
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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
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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
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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
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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
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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
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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
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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
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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
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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.
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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.