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  1. Slide 1 (ppt file)

    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/vtguide/hopkinsinternalmed-slides.ppt
    January 01, 2013 - Am J Hematol. 2013; 88:545-549 Major Risk Factors Age > 60 Cancer Previous VTE Acute CVA w/ paresis … Factor 1 - No contraindications 2 - Contraindications 3 - Systemic Anticoagulation 6 - No Risk Factors … weight, renal function and relevant labs imported from database Mandatory Selections Risk Factors
  2. www.ahrq.gov/sites/default/files/2024-09/temte-report.pdf
    January 01, 2024 - From a human factors point of view, this model is a Figure 1. … Demands, individual factors, and work system factors also contribute to workload. … Moreover, this is a validated and commonly used instrument in human factors engineering. … These approaches focus on separating human factors from system factors and provide the ability to understand … Turning the tide on medical errors in intensive care units: a human factors approach.
  3. www.ahrq.gov/practiceimprovement/delivery-initiative/alexander.html
    December 01, 2020 - System Change Manner in which a given DSC is implemented and practiced is influenced by range of factors … These factors constitute the social system or social context of change. … These factors may explain why, when, and how a DSC works (or not). … Fidelity and sustainability follow from interrelationships among a range of internal and external factors
  4. www.ahrq.gov/sites/default/files/wysiwyg/pqmp/lessons/lessons-performance-comparisons.pdf
    October 01, 2019 - Adjustments for demographic, clinical and social risk factors may be necessary to ensure that performance … The most common approaches used to account for these factors (demographic, clinical and social) are … Performance Comparisons 10 Figure 5: Adjustments for demographic, clinical and social risk factors … ‣ When assessing performance on process measures, risk adjustment should not include SES factors … Risk Adjustment for Socioeconomic Status or Other Sociodemographic Factors.
  5. www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/man1.html
    December 01, 2017 - Examples of these risk factors are illustrated in Figure 3 . Figure 3. … Common fall risk factors Intrinsic factors Effects of aging on gait, balance and strength … Extrinsic fall risk factors Environmental hazards. Unsafe equipment. … Examples of specific extrinsic risk factors Poor lighting. Cluttered living space. … Explore all possible causes and risk factors. Develop new strategies and revise plans.
  6. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/understand/understand-facilitator-guide.docx
    May 01, 2017 - Slide 5 SAY: As the illustration shows, at any given time, there are several system factors that … Task factors In addition to patient characteristics, task factors can shape the delivery of care and … Team factors Team factors may involve issues with teamwork, communication, inadequate supervision, and … Departmental factors When staffing issues, admission policies, and protocols prove to be insufficient … While these issues are the furthest removed from the patient in the diagram, these factors continually
  7. www.ahrq.gov/prevention/resources/chronic-care/clinical-community-relationships-eval-roadmap/ccre-roadmap-apa.html
    July 01, 2013 - ( Clinical-Community Relationships Measures Atlas [ Dymek et al., 2013 ]), we pair the six basic factors … A linkage, therefore, represents the combined influence of all six basic factors in the actual realization … It is important to note that the symmetry of the diagram does not imply that each of the basic six factors … In fact, the relative influence of factors is generally expected to vary according to the particular … The relevance of situational variability in the influence of different factors, including the clinical-community
  8. www.ahrq.gov/research/findings/final-reports/index.html?page=7
    January 01, 2024 - These topics include human factors approaches to improve patient safety, patient safety measure development … Number: R18 HS 024143 Topic(s): Health Information Technology and Health Information Exchange, Human Factors … Grant Number: R03 HS 22362 Topic(s): Education and Training, Emergency Care, Human and Environmental Factors … , Human Factors Approaches To Improve Patient Safety Publication Date: September 2015 Developing … Investigators: Singh Grant Number: R13 HS 021774 Topic(s): Conference, Diagnostic Safety, Human Factors
  9. www.ahrq.gov/research/findings/final-reports/index.html?page=5
    January 01, 2024 - These topics include human factors approaches to improve patient safety, patient safety measure development … Principal Investigators: Li and Chang Grant Number: R03 HS 024633 Topic(s): Human and Environmental Factors … application/pdf 524873 ) Principal Investigators: Blocker Grant Number: R13 HS 025876 Topic(s): Human Factors … /pdf 1331932 ) Principal Investigators: Sapirstein Grant Number: P30 HS 023553 Topic(s): Human Factors … Number: R18 HS 022860 Topic(s): Health Information Technology and Health Information Exchange, Human Factors
  10. www.ahrq.gov/research/findings/final-reports/stpra/stpraape.html
    April 01, 2018 - This period will allow us to account for risk factors stemming from surgical center staff interaction … Patient factors considered include: (1) comorbid condition; (2) family/social situations; (3) insufficient … Patient factors considered include: (1) staff hygiene/cleanliness (e.g., colonized with MRSA); (2) institutional … breaks in sterile technique, and glucose control; and (7) post-operative care issues (e.g., patient factors … , environmental factors, directions and understanding-dressing changes).
  11. www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/learn-from-defects-fac-guide.html
    July 01, 2023 - Rank these risk factors. … Visualize the factors that led to the event. Step 2. Identify the contributing factors. Step 3. … look at the technical factors. … by human factors. … Some of the codes for the factors are— TC: Technical, construction.
  12. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Grayson.pdf
    January 01, 2003 - , Laurie Wolf, Clay Dunagan, Gary Sorock, Bradley Evanoff Abstract Objective: Organizational factorsFactors such as nurse-to-patient ratio, nurse education, and hospital procedures have been identified … as important risk factors for patient safety.1–3 Few attempts, however, have been made to identify … also thought to be risk factors for medical errors. … is well suited for a study of proximate work environment factors leading to medical error.
  13. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Johnson.pdf
    January 01, 2004 - These three factors were found to interact in various ways and influenced one another. … The code “PR-FC,” for instance, stands for influencing factors in the purchasing process. … Do it by design: an introduction to human factors in medical devices. U.S. … Human factors implications of the new GMP rule. … Increasing the success of physician order entry through human factors engineering.
  14. www.ahrq.gov/funding/grantee-profiles/grtprofile-nishisaki.html
    July 01, 2025 - These adverse events are influenced by patient, provider, and practice factors. … pediatric ICUs that documents outcomes of tracheal intubations based on patient, provider, and practice factors … The pre-procedure checklist helps teams cross-check for patient risk factors that could affect the airway … funding from AHRQ, there would be no NEAR4KIDS database to document patient, provider, and practice factors
  15. www.ahrq.gov/sites/default/files/2024-09/secola-report.pdf
    January 01, 2024 - Secondary aims included the investigation of the association of selected risk factors utilizing both … Selected risk factors were not significantly associated with the development of a CVC-related BSI. … The secondary aims were to examine risk factors related to the development of CVC-related BSIs and … The selected risk factors in the five patients that developed BSIs are depicted in Table 3. … Several factors may have accounted for these preliminary results.
  16. www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/addressing-workforce-safety-062723.pdf
    July 25, 2023 - Clinical risk factors include patients who are under the influence of drugs or alcohol, those who are … Working extended shifts or under low staffing levels are also risk factors for workplace violence. … Worker-on-worker: Factors  Individual factors  Stressful and emotional work, fatigue  Inadequate … interpersonal, coping or conflict management skills  Systemic factors  Productivity demands, cost … Risk factors for patient-based violence Risk factors for patient-based violence Risk factors for patient-based
  17. www.ahrq.gov/hai/cusp/modules/understand/science-safety-notes.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. … Task factors In addition to patient characteristics, task factors can shape the delivery of care and … Team factors Team factors may involve issues with teamwork, communication, inadequate supervision, … What work environment factors were identified in the video?
  18. www.ahrq.gov/sites/default/files/2024-02/zierler-report.pdf
    January 01, 2024 - Improve the assessment of risk factors for VTE upon admission and discharge. … , systems characteristics, and potentially other factors. … for VTE (no risks – 46.3%, 1-2 risk factors – 60.3%, ≥3 risk factors – 80.5%, p<.001). … , p=.013 patients with ≥3 risk factors). … Nine of 12 patients who had incomplete CT scans had one or more VTE risk factors.
  19. www.ahrq.gov/hai/tools/surgery/modules/on-boarding/science-of-safety-slides.html
    December 01, 2017 - Slide 9: System Factors Impact Safety 5 Image:  Funnel depicting the factors that come together to … From the top of the funnel to the bottom, these factors include: institutional, hospital, departmental … factors, the work environment, team factors, individual provider, task factors, and patient characteristics … An arrow points through the system factors into the funnel. … Teamwork and communication: communication failure: basic components, contributing factors, and the call
  20. www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/169-cusp-science-safety-slides.pptx
    October 01, 2024 - Safe systems can be designed by applying human factors and other approaches to address technical problems … Environmental factors such as staffing, workflows, equipment, and the flow of people through the space … Careful and honest review of these factors improves patient safety; the CUSP framework is helpful. … What are some of the system factors that contributed to Susan’s death? … Consider all factors, or holes in the system, that led to this outcome.

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