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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/024-ss-cusp-learning-from-defects.pptx
April 01, 2025 - There are numerous contributing factors behind each defect. … outcomes.2-4
Capture all contributing factors before considering any interventions or solutions. … Ask “why” five times to drill down to the root of understanding each cause and the relevant factors. … factors, related to devices, procedures, and information technology
Healthcare personnel factors, related … to members of the healthcare team
Team factors, related to teamwork and communication
Institutional
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www.ahrq.gov/research/findings/final-reports/index.html?page=8
January 01, 2024 - These topics include human factors approaches to improve patient safety, patient safety measure development … Grant Number: R03 HS 21558 Topic(s): Healthcare Facility Design, Human Factors Approaches To Improve … Grant Number: K08 HS 019005 Topic(s): Emergency Care, Human and Environmental Factors, Risk Assessment … Grant Number: K01 HS 018987 Topic(s): Human Factors Approaches To Improve Patient Safety, Teamwork … ) Principal Investigators: Halpern Grant Number: K08 HS 18406 Topic(s): Human and Environmental Factors
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www.ahrq.gov/research/findings/final-reports/index.html?page=3
January 01, 2024 - These topics include human factors approaches to improve patient safety, patient safety measure development … Grant Number: P30 HS 023558 Topic(s): Human Factors Approaches To Improve Patient Safety, Patient Safety … Topic(s): Consumer Assessment of Healthcare Providers and Systems, Healthcare Facility Design, Human Factors … Principal Investigators: Sarcevic Grant Number: R03 HS 026057 Topic(s): Human and Environmental Factors … : Communication and Teamwork, Health Information Technology and Health Information Exchange, Human Factors
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www.ahrq.gov/research/findings/final-reports/index.html?page=1
January 01, 2024 - These topics include human factors approaches to improve patient safety, patient safety measure development … Grant Number: R18 HS 026625 Topic(s): Human Factors Approaches To Improve Patient Safety, Medication … Grant Number: R01 HS 026134 Topic(s): Human and Environmental Factors Publication Date: April 2023 … Grant Number: R18 HS 026609 Topic(s): Diagnostic Safety, Human Factors Approaches To Improve Patient … Grant Number: R03 HS 027231 Topic(s): Discharge Planning, Human Factors Approaches To Improve Patient
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www.ahrq.gov/sites/default/files/2025-04/polgren-miller-report.pdf
January 01, 2025 - We also investigated potential risk factors
associated with diagnostic delays. … Risk factors for delay included urinary tract infection
history and morbid obesity. … We also studied the frequency and risk factors for diagnostic delays of Dengue
fever. … “Frequency, Duration of, and
Risk Factors for Diagnostic Delays Associated with Sepsis.” … Frequency, Duration of, and Risk Factors
for Diagnostic Delays Associated with Sepsis.
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/004-cusp-learning-from-defects.docx
October 01, 2024 - There are usually numerous contributing factors behind each defect. … To truly understand the cause and the factors, ask “why” five times to drill down to the root. … Slide 13
Contributing Factors
SAY:
Contributing factors often include the following:
· Patient factors … Team factors, related to teamwork and communication
· Institutional factors, related to the institution … contributing factors, the CUSP team sorted them using the cause-frequency grid.
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www.ahrq.gov/sites/default/files/2025-05/schuur-report.pdf
January 01, 2025 - aimed to address infection prevention in the emergency department, through 4
main domains: 1) human factors … to other settings and these factors directly affects
the use of infection control practices. … Human Factors and Quality Improvement
Prior to the conference, the workgroup focused on human factors … Attendees participated in
exercises where they could apply the factors to the emergency department. … Other factors included: HIT
processes are not always productive, consistency of cleaning processes,
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/023-ss-cusp-learning-from-defects-fg.docx
April 01, 2025 - There are usually numerous contributing factors behind each defect. … To truly understand the cause and the factors, ask “Why” five times to drill down to the root. … Slide 13
Contributing Factors
SAY:
Contributing factors often include the following:
· Patient factors … Team factors, related to teamwork and communication
· Institutional factors, related to the institution … contributing factors, the CUSP team sorted them using the cause-frequency grid.
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/131-ss-swiss-cheese.pptx
April 01, 2025 - Surgical Services
The Swiss Cheese Model
Systems Impact Safety2
Institutional
Hospital
Departmental Factors … Work Environment
Team Factors
Individual Provider
Task Factors
Patient Characteristics
| 7
AHRQ Safety … | 9
AHRQ Safety Program for MRSA Prevention | Surgical Services
The Swiss Cheese Model
System Factors … | 10
AHRQ Safety Program for MRSA Prevention | Surgical Services
The Swiss Cheese Model
System Factors … Multiple factors contribute to patient outcomes.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/ontimefallpxsamplereports.pdf
June 02, 2025 - • 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: ___/__
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/chtoolbx/choosing/choosing.doc
June 02, 2025 - 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.
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www.ahrq.gov/research/findings/final-reports/index.html?page=4
January 01, 2024 - These topics include human factors approaches to improve patient safety, patient safety measure development … Grant Number: R03 HS 25548 Topic(s): Human and Environmental Factors, Measure Development, Measure … Grant Number: R18 HS 024679 Topic(s): Healthcare Facility Design, Human Factors Approaches To Improve … , Human Factors Approaches To Improve Patient Safety, Patient Safety Learning Laboratory Publication … Grant Number: R18 HS 024887 Topic(s): Healthcare Facility Design, Human Factors Approaches To Improve
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-woods_79.pdf
May 30, 2008 - Step 3.2: Criteria – Performance-shaping factors. … The performance-shaping factors follow the framework
presented by Charles Vincent as “factors that influence … Step 3.3: Criteria – Child-specific risk factors. … demonstrated how these factors
contribute to patient safety risk. … Performance-shaping factors in health care
1.
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www.ahrq.gov/practiceimprovement/delivery-initiative/casalino/paper/idkeydsrapc.html
February 01, 2014 - What are the factors that influence this? … What factors encourage or discourage the use of the process? … What factors encourage or discourage the use of the process? … What factors encourage or discourage the use of the process? … Factors promoting patient engagement
What organizational structural, cultural, and process factors
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/understand-sci-slides.html
July 01, 2023 - Slide 6: System-Level Factors Affect Safety 6
Image: Concentric circles show the layered impact of … Institutional factors, hospital factors, departmental factors, work environment factors, team factors … , individual provider factors and task factors all have an impact on patient safety. … Slide 7: System-Level Factors Can Predict Performance
Examples of Impact of System-Level Factors … Communication failure: basic components, contributing factors, and the call for structure.
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/170-cusp-science-safety-notes.docx
October 01, 2024 - to recognize and address the underlying factors that can cause safety problems. … )
Task Factors (e.g., task is unclear, equipment not available)
Provider Factors (e.g., insufficient … Slide 21
What System Factors Did You Identify? … These are just some of the system factors at play. … Some of these system factors were local, part of the microsystem providers worked in.
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/124-cusp-science-safety-fg.docx
April 01, 2025 - to recognize and address the underlying factors that can cause safety problems. … )
Task Factors (e.g., task is unclear, equipment not available)
Provider Factors (e.g., insufficient … factors that contributed to Marta’s rehospitalization and SSI? … These are just some of the system factors at play. … Some of these system factors were local, part of the microsystem providers worked in.
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www.ahrq.gov/research/findings/final-reports/ssi/ssiexecsum.html
April 01, 2018 - Initial Risk Factors
Appendix J. Additional Risk Factors
Appendix K. … Final Risk Factors
Appendix L. … Final data sheet submitted by each site that included the list of potential SSI risk factors and other … Focus Group Risk Factors
Appendix Q. Surgeon Focus Group Content Analysis
Appendix R. … The approach for screening additional risk factors, analytic results, and recommendations are presented
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www.ahrq.gov/research/findings/final-reports/iomracereport/reldata1fig12txt.html
April 01, 2018 - Macrosocial factors (historical conditions, economic structures, political order, legal codes, and social … Geographic origins & biological factors (morphological, physiological, biochemical, or genetic). … Risk factors & resources (health behaviors, stress, medical care, social ties, psychological, cultural … , or religious factors). … An arrow points down from Social statuses to Risk factors & resources ; an arrow "tree" also points
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/fallpxreports.pptx
October 01, 2017 - Falls Prevention
Electronic Reports
Electronic Reports
Falls High-Risk Report
Summary of Fall Risk Factors … (by Unit or Facility)
Contextual Factors Report (by Unit or Facility)
Postfall Assessment Report (by … What are the most common risk factors?
Which acute change was seen most often? Least often? … Report can be used to monitor overall prevalence and trends of risk factors associated with falls on … -MEH
36
Check Your Understanding:
Contextual Factors Report Quiz
For the Contextual Factors Report