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Showing results for "factors".

141. Taxonomic Guidance for Remedial Actions (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Thomadsen.pdf
     December 23, 2004 - Most often, removing any one of the factors might prevent the event. … such as organizational factors or environmental-shaping factors that contributed to the event. … Other shaping factors include external factors, environmental factors, and organizational factors. … Two of these factors are expanded in the fourth tier (see Figure 3). … The table lists fixing environmental factors first.

142. Chapter 6. Conclusions and Recommendations | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/ssi/ssi6.html
     April 01, 2018 - Initial Risk Factors Appendix J. Additional Risk Factors Appendix K. … Final Risk Factors Appendix L. … Focus Group Risk Factors Appendix Q. Surgeon Focus Group Content Analysis Appendix R. … We need to investigate risk factors as surgery specific. … Validate risk factors more broadly on a national scale.

143. Understand the Science of Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/modules/understand/science-safety-slides.html
     July 01, 2018 - System-Level Factors Affect Safety 9 Slide 8. Safety is a Property of the System Slide 9. … System-Level Factors Can Predict Performance Slide 10. … show the layered system-level factors that affect patient safety: institutional factors, hospital factors … , departmental factors, work environment factors, team factors, individual provider factors, and task … factors all have an effect on patient safety.

144. TO (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d8_combo_projectevaluation.docx
     June 02, 2025 - 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.

145. Final Progress Report: The Institute for the Design of Environments Aligned for Patient Safety (IDEA4PS) (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/mcalearney-report.pdf
     January 01, 2024 - Hum Factors. 60(3):281-92. PMID:29533682 20. … Human Factors in Healthcare Symposium, Chicago, IL, Mar 24, 2019. 72. … Human Factors in Healthcare Symposium, Chicago, IL, Mar 24, 2019. 73. … Human Factors in Healthcare Symposium, Chicago, IL, Mar 24, 2019. 74. … Human Factors in Healthcare Symposium, Chicago, IL, Mar 24, 2018. 76.

146. System-Focused Event Investigation and Analysis Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4.html
     August 01, 2022 - Redesign of system factors. … This information is the starting point in determining the contributing factors. … to build consensus around these factors. … These factors are the focus of the solutions meeting. … To determine which contributing factors are most critical, chart the factors evaluating impact and likelihood

147. Event Investigation and Analysis Guide: Appendix I | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/api.html
     August 01, 2022 - Causal factor: the suspected or confirmed factors that caused the adverse event. … Often, multiple factors must intersect for an adverse event to reach the patient. … Labeling one or even several of these factors as "causes" may place undue emphasis on a single specific … The purpose of the event review and analysis is to help clarify the causal factors. … Event review: the overall process of assessing an adverse safety event to determine contributing factors

148. Focusing on Health Equity in AHRQ's PCORTF Investments | Agency for Healthcare Research and Quality
     www.ahrq.gov/pcor/strategic-framework/investments.html
     July 01, 2023 - An equity lens provides a deliberate focus on understanding and addressing factors at multiple levels … of influence (policies, systems, and environmental factors; institutional and organizational factors … ; community-level factors; and individual factors) that can advance fair and just opportunities to attain

149. PowerPoint Presentation: Learn From Defects Through Sensemaking
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/implementation/imp_learn_from_defects.pptx
     December 01, 2017 - Hospital Departmental Factors Work Environment Team Factors Individual Provider Task Factors … Your institution, hospital factors, departmental factors, work environment, and team factors all contribute … SAY: Keep track of these key factors. 18 LFD Tool Contributing Factors Learning From Defects 19 … Identify the top contributing factors. … The goal is to tease out systemic factors that contribute to errors and improve upon those factors.

150. Final Progress Report: Malpractice Insurers’ Medical Error Surveillance and Prevention Study (MIMESPS) (pdf file)
     www.ahrq.gov/sites/default/files/2024-09/studdert-report.pdf
     January 01, 2024 - Key words: patient safety, medical error, medical malpractice, litigation, human factors 2 2. … To assess how the errors and contributing factors identified in claims file analysis compare to those … For the rest, reviewers considered the potential contributory role of 17 “human factors” in causing … We found that systems factors played a critical role in the occurrence of errors. … setting was 3; 59% had >3 contributing factors, 27% had >4, and 13% had >5

151. Understanding Physicians' and Patients' Views of Harms and Clinical Preventive Services (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/decision/research-centers/vu_physician_patient_harms.pdf
     June 02, 2025 - of health issues, little is known about how physicians think about these screening services or the factors … For every patient, physicians must weigh different factors that influence a screening decision, including … Gaining insights about which factors physicians consider and how they handle conflicting information … Do physicians know about the harms of screening tests and consider them in relation to other factors … What factors are most important for physicians when making screening recommendations?

152. PS Grantee | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/index.html?page=14
     January 01, 2024 - These topics include human factors approaches to improve patient safety, patient safety measure development … pdf 955307 ) Principal Investigators: Karsh, et al Grant Number: P20 HS 017115 Topic(s): Human Factors … Grant Number: P20 HS 017139 Topic(s): Human and Environmental Factors, Measure Development, Measure … Grant Number: U18 HS 015906 Topic(s): Human and Environmental Factors, Human Factors Approaches To … Grant Number: R03 HS 015732 Topic(s): Healthcare Facility Design, Human Factors Approaches To Improve

153. Chapter 4. Choose the Model To Assess VTE and Bleeding Risk | Agency for Healthcare Research and Quality
     www.ahrq.gov/es/patient-safety/settings/hospital/vtguide/guide4.html
     October 01, 2022 - Minor ambulatory surgery unless multiple strong risk factors. … The model includes a scoring system with several sets of risk factors. … They included risk factors that developed during the hospital stay as well as factors present on admission … or multiple other risk factors. 14 Note that several of these risk factors are also frequently listed … as risk factors for VTE.

154. Chapter 4. Choose the Model To Assess VTE and Bleeding Risk | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/vtguide/guide4.html
     October 01, 2022 - Minor ambulatory surgery unless multiple strong risk factors. … The model includes a scoring system with several sets of risk factors. … They included risk factors that developed during the hospital stay as well as factors present on admission … or multiple other risk factors. 14 Note that several of these risk factors are also frequently listed … as risk factors for VTE.

155. Session 1 | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/mod3sess3.html
     October 01, 2014 - What are his risk factors for falling? … P What are his risk factors for falling? … of risk factors. … The second group of risk factors has to do with the environment.   … Risk Factors Related to the Resident The most important risk factors for falls having to do with the

156. TO (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/d8_pdi_projectevaluation.docx
     June 02, 2025 - 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.

157. AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention Training | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/reportguide.html
     November 01, 2017 - Contextual Factors Report (by Unit or Facility) . … of Falls Risk Factors report. … Slide 31: Contextual Factors Report Say: Now let’s begin by going over the Contextual Factors Report … Slide 32: Contextual Factors Report Say: The Contextual Factors Report displays information for … Contextual Factors Report by Month handout.

158. Patient Safety Learning Laboratory to Enhance the Value and Safety of Neonatal Interfacility Transfers in a Regional Care Network | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/resources/learning-lab/neonatal-interfacility-transfers-long-desc.html
     January 01, 2025 - Patient factors:  Age, weight, gestation,  Vital signs (temperature, heart rate, respiratory rate),  … Proc Hum Factors Ergon Soc Annu Meet  2023;67(1):79-85. Fang JL, et al. … Neonatal vital sign trajectories and risk factors during transport within a regional care network . … Proc Hum Factors Ergon Soc Annu Meet  2023;67(1):79-85. Greene ND, et al.  … Neonatal vital sign trajectories and risk factors during transport within a regional care network .

159. Appendix A. Teleconferences with AHRQ & CDC | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/ssi/ssiapa.html
     April 01, 2018 - Initial Risk Factors Appendix J. Additional Risk Factors Appendix K. … Final Risk Factors Appendix L. … listing SSI risk factors. … Task 3 The list of identified risk factors is to include all factors-including modifiable/non modifiable … Task 3 The list of identified risk factors is to include all factors—including modifiable/non modifiable

160. 110-Ss-Lfd-Sample (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/110-ss-lfd-sample.docx
     April 01, 2025 - Positive contributing factors limited the amount of harm. … Rate the most important contributing factors that relate to the incident. III. … Contributing Factors Domain Contributing Factors Negatively Contributed Positively Contributed … Protocol for determining risk factors for MRSA colonization in electronic health record. … N/A Other: N/A Prioritizing Factors Review the list of contributing factors above and identify