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Total Results: 3,576 records

Showing results for "factors".

241. Prologue: The Shift toward Performance and Tools (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Prologue_Keyes_Vol3.pdf
     June 02, 2025 - approaches that underscore the importance of teamwork and communication, the incorporation of human factors … yet to be addressed. 1 Following the simulation section, the reader finds papers on human factors … Since World War II, the role of human factors in high performance and high stress environments has been … section, the authors of five papers, representing different clinical settings, address a range of human factors … operating rooms of the future, transitions of care, the use of resilience engineering, and human factors

242. Learn Module Alternate Text | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/modules/learn/alt-text.html
     April 01, 2013 - Slide 22 System-Level Factors Impact Safety 5 Institutional Hospital Departmental Factors … Work Environment Team Factors Individual Provider Task Factors Patient Characteristics … Concentric circles show the layered factors of patient safety. … Institutional factors, hospital factors, departmental factors, work environment factors, team factors … , individual provider factors, task factors, and patient characteristics all have an effect on patient

243. Final Progress Report: Further Psychometric Testing and Validation of the Errors of Care Omission Survey (ECOS) (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/poghosyan-report.pdf
     January 01, 2025 - We ran several models in which the factors corresponded to each omission domain, and we also allowed … the factors to emerge from the data. … Then, we determined the number of factors to be extracted by evaluating model fit. … System-related factors contributing to diagnostic errors. … Factors influencing why nursing care is missed.

244. Grants to Enable Diagnostic Excellence | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/diagnostic-error-grants/index.html
     January 01, 2021 - To combine adjudication data with data from Vizient to determine which specific factors contribute to … risks for diagnostic errors, and to use risk estimates to calculate incidence and impact of factors … breakdowns and (b) apply this new analytic tool to establish the incidence, types, and contributing factors … To identify the risk factors associated with diagnostic delays for infectious diseases that are frequently

245. Work System Analysis: The Key to Understanding Health Care Systems (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Karsh.pdf
     April 22, 2004 - • What other environmental factors impact the system? … Human factors in engineering and design. New York, NY: McGraw- Hill, Inc; 1993. 8. … Hum Factors 1996 Dec;38(4):593–613. 28. Berg M, Langenberg C, vd Berg I, et al. … Paper presented at Human Factors and Ergonomics Society; 2003 Oct; Denver. 35. … Santa Monica, CA: Human Factors and Ergonomics Society; 2000. 36. Pasmore W.

246. Patient Safety Learning Pilot: Narratives from the Frontlines (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Kellie_30.pdf
     April 21, 2008 - in learning from events, there has been little study of how these factors are received and used by … Human Factors Engineering Human factors engineering is the discipline focused on understanding how the … • Notes from sensemaking and human factors consultation visits to hospitals. … Human Factors Engineering Human factors educational sessions were convened at each of the three learning … “Managers will need more extensive training to understand human factors.

247. AHRQ's Safety Program for Nursing Homes: On-Time Falls Prevention Training (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/fallspximpl-handouts.pdf
     June 02, 2025 - Remember the Monthly Contextual Factors Report? … Facilitator: What’s most important is to pay attention to the major risk factors. … We also talked about adding training for nursing assistants on risk factors for falls. … Contextual Factors Report. … To be able to view these contextual factors in aggregate is going to be great.

248. Eliminating CLABSI, A National Patient Safety Imperative: Final Report Companion Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/clabsi-final-companion/index.html
     January 01, 2013 - Pediatric Units Infections Avoided, Excess Costs Averted, and Changes in Mortality Rate Moderating Factors … Moderating Factors Flowchart Appendix F. Team Checkup Tools Appendix G. … Review—Methods         Literature Review—Results         Estimation Method         Results Moderating Factors … Moderating Factors Flowchart Appendix F.

249. Learn From Defects - Implementation Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/training-tools/defects.html
     May 01, 2017 - (what factors contributed) positive factors What prevented it from being worse?   … negative factors What happened to cause the defect?   3.

250. Development and Implementation of The University of Texas Close Call Reporting System (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Martin.pdf
     March 01, 2004 - to use to recognize the etiology of close calls with respect to human and systems factors. … occurred 1 month after the first session—resulted in 18 specific contributing factors. … However, there was a great deal of confusion about the specific meaning of the factors. … , sentences associated with the contributing factors, and narratives. … Human-factors analysis using standard methodology for computer systems was also conducted.

251. Bridging Community-based Continence Promotion and Primary Care (WI-INTUIT) (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/projects/urinary/evidencenow-wi-intuit.pdf
     January 01, 2025 - Examine the impact of implementation strategy and contextual factors on intervention Reach, Adoption … Identify the impact of intervention components and contextual factors on patient-reported outcomes. … understand why implementation succeeded or failed for each practice and to identify relevant modifiable factors … participating practice staff, patients, practice facilitators, and community partners are used to characterize factors … practices with participatory design principles from community-based participatory research and human factors

252. Clinical Inertia and Outpatient Medical Errors (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/OConnor.pdf
     January 01, 2003 - We postulate that clinical inertia has three principal sources: physician factors, patient factors … , and office system factors. … system factors to clinical inertia. … Patient factors that contribute to clinical inertia Patient factors that contribute to the problem … factors, patient factors, and office system factors—will be powerful enough to reduce the rate of clinical

253. Final Progress Report: Patient-Centric Risk Model for Medication Safety During Care Transitions (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/gurses-report.pdf
     January 01, 2024 - The tool assesses risk factors at three time points. … Evaluation of the risk factors for medication discrepancies. … Patient-centered risk factors. … Human Factors and Ergonomics Society Meeting, 2018, Philadelphia, PA. … Readmission risk factors after hospital discharge among the elderly.

254. Learn from Defects Tool | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/toolkit/learn-defects.html
     December 01, 2012 - Negative contributing factors are those that harmed or increased the risk of harm for a patient. … Positive contributing factors limited the amount of harm. … Rate the most important contributing factors that relate to the incident. … Rate the most important negatively contributed and positively contributed factors that relate to this … Develop interventions to defend against the two to five most important contributing factors.

255. Learn From Defects - Implementation Guide | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/ambulatory-surgery/sections/implementation/training-tools/learn.html
     April 01, 2017 - (what factors contributed) positive factors What prevented it from being worse?   … negative factors What happened to cause the defect?   3.

256. Learn From Defects | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/implementation/long-term-modules/module2/defects.html
     March 01, 2017 - (what factors contributed)   positive factors What prevented it from being worse?   … negative factors What happened to cause the defect?   3.

257. Cancer Patient Safety Learning Laboratory (CaPSLL): Preventing Clinical Deterioration in Outpatients | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/resources/learning-lab/preventing-clinical-deterioration-long-desc.html
     January 01, 2025 - Proc Hum Factors Ergon Soc Annu Meet  2023;67(1):589-592. Salwei ME, et al. … Human Factors and Ergonomics Society (HFES) 66th International Annual Meeting. … International Symposium on Human Factors and Ergonomics in Health Care. … Proc Hum Factors Ergon Soc Annu Meet  2020;64(1):671-674. References Weinger MB. … Proc Hum Factors Ergon Soc Annu Meet  2020;64(1):593-597. Salwei ME, et al. 

258. Brain Health Patient Safety Learning Laboratory (Brain Safety Lab) | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/resources/learning-lab/brain-health-long-desc.html
     April 01, 2021 - Abebe E, Medication transitions: vulnerable periods of change in need of human factors and ergonomics … Proc Int Symp Hum Factors Ergon Healthc.  2020;9(1):180-2. Andrews PS, et al.  … Human factors in pharmacy . … Proc Hum Factors Ergon Soc Annu Meet.  2017;61(1):666-70. 2016 Clark DO, et al.  … Proc Int Symp Hum Factors Ergon Healthc. 2020;9(1):180-2.

259. Conclusions | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/clabsi-hpwpreport/clabsi-hpwp4.html
     August 01, 2015 - Our findings provide insight about both the management practices and factors associated with more successful … The success factors emphasized by the higher performing sites included (1) a belief that a rate of zero … In contrast, several factors created challenges to CLABSI reduction efforts: (1) resource constraints … While it is difficult to eliminate other explanations for why success factors were more likely found … those from a study of five collaborative regional HAI programs, which identified the following success factors

260. National Academy of Medicine (NAM) Reports | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/reports/national-academy-medicine.html
     February 01, 2018 - Health Care Comes Home: The Human Factors is a 2011 report that outlines the impact of technology, environment … , policy and regulation, and human factors on the growing field of home health care. … companion to the report, the National Academy of Sciences and AHRQ published a designer's guide to human factors … for consumer health IT, Consumer Health Information Technology in the Home: A Guide for Human Factors … Read the Institute of Medicine Report and Designer's Guide on Bringing Human Factors into Home Health