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  1. 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.
  2. 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
  3. 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
  4. www.ahrq.gov/hai/cusp/modules/spread/notes.html
    December 01, 2012 - External Factors Affecting Spread 3 Slide 7. Internal Factors Affecting Spread 3 Slide 8. … Factors That Affect Spread Slide 9. What Facilitates Spread Success? 4 Slide 10. … External Factors Affecting Spread 3 Say: Several external and internal factors can influence spread … Internal Factors Affecting Spread 3 Say: Internal factors include: Leadership: Does the process … Factors That Affect Spread Do: Play the video.
  5. www.ahrq.gov/hai/cusp/clabsi-final-companion/clabsicomp1.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. … This document is broken into four primary sections: Methods, Participation, Outcomes, and Moderating Factors … Finally, the Moderating Factors section examines variation in CLABSI rates found in the project.
  6. Defects (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/implementation/long-term-modules/module2/defects.docx
    March 01, 2017 - (what factors contributed) positive factors What prevented it from being worse? … negative factors What happened to cause the defect? 3. What did we do to manage it? 4.
  7. Defects (doc file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/implementation/training-tools/defects.docx
    May 01, 2017 - (what factors contributed) positive factors What prevented it from being worse? … negative factors What happened to cause the defect? 3. What did we do to manage it? 4.
  8. www.ahrq.gov/research/findings/studies/index.html
    January 01, 2025 - Ranawat Award: Factors that predict outcome five years following total knee arthroplasty. … The purpose of this study was to identify factors that predict pain and functional outcomes five years … For functional outcomes, similar factors were significant, with additional influence from body mass index … Ranawat Award: Factors that predict outcome five years following total knee arthroplasty. … Factors associated with repeat pediatric influenza vaccination among inconsistent vaccinators.
  9. www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/d4i_pdi11-dehiscence-bestpractices.pdf
    May 17, 2016 - Although many risk factors are nonmodifiable (e.g., emergency surgery), some factors can be addressed … Determine risk factors for postoperative wound dehiscence and identify pediatric patients at risk.2- … Hospital Quality and Safety 2 Tool D.4i o Malnutrition • When possible, eliminate or mitigate risk factors … o Reported pain (if old enough to verbalize) or increased heart rate not accounted for by other factors … Risk factors for abdominal wound dehiscence in children: a case-control study.
  10. www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4w_combo_pdi11-dehiscence-bestpractices.pdf
    May 17, 2016 - Although many risk factors are nonmodifiable (e.g., emergency surgery), some factors can be addressed … Determine risk factors for postoperative wound dehiscence and identify pediatric patients at risk.2- … Hospital Quality and Safety 2 Tool D.4w o Malnutrition • When possible, eliminate or mitigate risk factors … o Reported pain (if old enough to verbalize) or increased heart rate not accounted for by other factors … Risk factors for abdominal wound dehiscence in children: a case-control study.
  11. www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-medication-chartbook-2024.pdf
    January 01, 2024 - ■ Human contributing factors such as fatigue, stress, inattention, cognitive factors, and/or health … Overall, patients of all age groups experienced similar rates of contributing factors for the event … Human Factors can include fatigue, stress, inattention, cognitive factors, and/or health issues experienced … for Near Miss Incorrect Actions The figure below examines contributing factors for Incorrect actions … Only the five most commonly reported contributing factors are displayed for brevity.
  12. www.ahrq.gov/patient-safety/resources/learning-lab/ripchdor-long-desc.html
    April 01, 2022 - Minor flow disruptions, traffic-related factors and their effect on major flow disruptions in the operating … Hum Factors 2018;60(7):992-1007. Jurewicz K, et al. … Proceedings of the Human Factors and Ergonomics Society Annual Meeting. 2018;62(1):469-73. https://journals.sagepub.com … The influence of traffic, area location, and other factors on operating room microbial load . … Proceedings of the Human Factors and Ergonomics Society Annual Meeting. 2017;61(1):696-700.
  13. www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/ontimefallpxoverviewmaterialspacket.pdf
    June 02, 2025 - • Quarterly Summary of Falls Risk Factors by Unit or Facility. … • Monthly Contextual Factors Report. • Postfall Assessment Summary Report. … O n-Tim e Falls P revention: E lectronic R eports 3 Quarterly Summary of Falls Risk Factors by … Report Sample Monthly Contextual Factors Report by Facility Monthly Contextual Factors Report Date … by Unit or Facility Monthly Contextual Factors Report Postfall Assessment Summary Report
  14. www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/index.html
    November 01, 2014 - Lean        Intermediate Outcomes        Ultimate Outcomes        Business or Strategic Case     Factors … Procedure Cards     Outcomes of Lean        Intermediate Outcomes        Ultimate Outcomes     Factors … Appointment Scheduling     Outcomes of Lean        Intermediate Outcomes        Ultimate Outcomes     Factors … Prescribing Process     Outcomes of Lean        Intermediate Outcomes        Ultimate Outcomes     Factors … Horizon Hospital     Outcomes of Lean        Intermediate Outcomes        Ultimate Outcomes     Factors
  15. www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-current-state3.html
    January 01, 2024 - Careful attention to sociotechnical factors, such as ensuring responsibility for closing the loop on … Incidence and Contributing Factors This domain covers the frequency of diagnostic errors and factors … Studies showcase the need for further research on contributory factors and targeted interventions. 2 … System factors. … System-related aspects of diagnosis (e.g., human factors, safety culture). 243 3.9.2.
  16. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol2/Advances-SinghG_67.pdf
    April 14, 2008 - The figure displays eight factors that, in our view, contribute to a safety culture.7 Although the relative … were primarily developed, the same six factors appeared to be robust in this setting. … Perceptions of management had the lowest alpha, while the other five factors all had alphas of ≥0.70 … However, there may be some measurable moderating factors, such as practice size and type, location, … ACSNI Study Group on Human Factors. 3rd Report: Organising for safety. London: HMSO; 1993. 20.
  17. www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/handout.html
    November 01, 2017 - Remember the Monthly Contextual Factors Report? … Facilitator: What’s most important is to pay attention to the major risk factors. … Nursing Assistant A: Shouldn’t we intervene on all risk factors? Facilitator: Yes. … Contextual Factors Report. … To be able to view these contextual factors in aggregate is going to be great.
  18. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Fein.pdf
    January 01, 2004 - This study aimed to construct a conceptual model of the factors that facilitate or hinder disclosure … Important influences on whether disclosure would occur fell into four categories: provider factors, … patient factors, error factors, and institutional culture. … The discussion then broadly explored factors associated with whether disclosure would occur. … , patient factors, error factors, and institutional culture.
  19. www.ahrq.gov/research/findings/final-reports/stpra/stpraapa3.html
    April 01, 2018 - Risk factors considered Patient level: age, sex, presence of diabetes, cardiovascular disease, end … Infectious Risk Factors Related to Operating Rooms. Didier Pittet, Georges Ducel. … Factors Influencing the Incidence and Outcome of Infection Following Total Joint Arthroplasty. … Risk Infection Factors in the Total Hip Replacement - Arjona et al. … Risk Factors for Surgical Site Infection Following Orthopedic Spinal Operations – Olsen et al.
  20. www.ahrq.gov/research/shuttered/acfselection/appendixc.html
    July 01, 2018 - The first column lists the specific factors as found in the tool. … protection of staff and patients. 3    2    1    0 3    2    1    0 Additional Infrastructure Factors … used for staff rest and rehab. 3    2    1    0 3    2    1    0 Additional Space/Layout Factors … wired for IT and internet access. 3    2    1    0 3    2    1    0 Additional Communication Factors … site to referral hospitals. 3    2    1    0 3    2    1    0 Additional "Other Services" Factors

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