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www.ahrq.gov/hai/tools/mvp/modules/cusp/science-of-safety-fac-guide.html
February 01, 2017 - factors, such as the economic and regulatory state of your organization. … Departmental factors, such as staffing levels and managerial support. … Team factors, such as team structure and quality of verbal communication. … Individual provider factors, such as knowledge, skills, and motivations. … Task factors, such as clarity of structure and accuracy of test results.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/learn-from-defects-slides.pptx
January 01, 2017 - able to—
Describe difference between first-order and second-order problem solving
List contributing factors … Contributing factors from all levels of your health care system impact care delivery and, ultimately, … patient outcomes
Develop a “system perspective” to see the hidden factors that led to the event
List … Work Environment
Team Factors
Individual Provider
Task Factors
Patient Characteristics … for Mechanically Ventilated Patients
LFD Tool Contributing Factors
Learn From Defects ‹#›
AHRQ
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d8_combo_projectevaluation.pdf
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.
3. … EVALUATION
What factors helped the team succeed? What factors hindered the team’s success?
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www.ahrq.gov/patient-safety/settings/emergency-dept/frequent-use.html
July 01, 2017 - Return to Contents
Study Overview
The ultimate goal of this study was to identify the factors that … From the factors identified in the scan, the JHU team selected six “modifiable” factors associated with … Modifiable risk factors were those the research team judged could be alleviated or addressed through … The six selected factors were:
Lack of insurance;
Lack of primary care physician;
Psychiatric … They also created a sample User's Guide listing interventions targeting the risk factors. i
Between
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www.ahrq.gov/research/findings/final-reports/ssi/ssiexh48.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.
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www.ahrq.gov/research/findings/final-reports/ssi/ssiexh49.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.
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www.ahrq.gov/research/findings/final-reports/ssi/ssiexh52.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.
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www.ahrq.gov/research/findings/final-reports/ssi/ssiexh11.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.
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www.ahrq.gov/hai/tools/surgery/modules/implementation/learn-from-defects-slides.html
December 01, 2017 - Slide 17: System Factors Impact Safety 3
Image: Funnel of factors that impact patient safety: … Departmental factors.
Work environment.
Team factors.
Individual provider.
Task factors. … As you identify contributing factors, try to go deeper. … Other Factors
Hospital environment : Transfer across units. … Identify the top three contributing factors.
Share those factors with your staff.
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-surgery/111-cusp-learning-from-defects-worksheet.docx
April 01, 2025 - Top Contributing Factors
Interventions To Reduce Risk
Who Will Do It and By When
Status
Enter contributing … What Are the Top Contributing Factors? … Enter contributing factors
Defect Identified: What Is the Defect?
Enter defect
AHRQ Pub.
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/111-ss-cusp-lfd-worksheet-a3.docx
April 01, 2025 - Top Contributing Factors
Interventions To Reduce Risk
Who Will Do It and By When
Status
Enter contributing … What Are the Top Contributing Factors? … Enter contributing factors
Defect Identified: What Is the Defect?
Enter defect
AHRQ Pub.
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www.ahrq.gov/research/findings/final-reports/index.html?page=11
January 01, 2024 - These topics include human factors approaches to improve patient safety, patient safety measure development … Kutney-Lee Grant Number: K08 HS 018534 Topic(s): Education and Training, Human and Environmental Factors … 017902 Topic(s): Emergency Care, Health Information Technology and Health Information Exchange, Human Factors … Etchegaray Grant Number: K02 HS 017145 Topic(s): Communication and Teamwork, Human and Environmental Factors … Grant Number: R03 HS 19074 Topic(s): Healthcare Facility Design, Human Factors Approaches To Improve
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www.ahrq.gov/research/findings/final-reports/index.html?page=16
January 01, 2024 - These topics include human factors approaches to improve patient safety, patient safety measure development … Principal Investigators: Sampselle Grant Number: R13 HS 016436 Topic(s): Human and Environmental Factors … pdf 446002 ) Principal Investigators: Bates, et al Grant Number: P01 HS 011534 Topic(s): Human Factors … Investigators: Ellenbecker and Boylan Grant Number: R01 HS 13477 Topic(s): Human and Environmental Factors … Grant Number: P01 HS 011530 Topic(s): Human and Environmental Factors, Human Factors Approaches To
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www.ahrq.gov/sites/default/files/publications/files/ltcmodule3.pdf
June 01, 2012 - What are his risk factors for falling? … Risk Factors Related to the Resident
The most important risk factors for falls having to do with the … , environmental factors, and factors in care or equipment. … Risk factors are always present. We all have risk factors for falls. … tailored to those risk factors.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/science-of-safety-facguide.docx
January 01, 2017 - Slide 5
System Factors Impact Safety
SAY:
Each level of the health care delivery system matters. … SAY:
The following are all factors that impact safety in the health care system:
· Institutional factors … , such as the economic and regulatory state of your organization
· Hospital factors, such as financial … support
· Work environment factors, such as shift patterns and equipment maintenance
· Team factors, … , skills, and motivations
· Task factors, such as clarity of structure and accuracy of test results
·
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www.ahrq.gov/research/findings/final-reports/ssi/ssiexh16.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.
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www.ahrq.gov/research/findings/final-reports/ssi/ssiexh17.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.
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www.ahrq.gov/research/findings/final-reports/ssi/ssiexh6.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.
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www.ahrq.gov/research/findings/final-reports/ssi/ssiapg.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.
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www.ahrq.gov/sites/default/files/2024-10/smucker-report.pdf
January 01, 2024 - Some of these factors
include the following:
• Hospice care provided in a patient’s home creates a … Contributing factors/hazards are circumstances, actions, or influences that are thought
to have played … (Specific Aim 1: Types, characteristics, contributing factors)
1. … Characteristics and contributing factors: Once the respondent completed a general
description of the … , caregiver factors, or home living situations.