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Showing results for "factors".

321. Tool 2: Readmission Review Tool (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/medicaidreadmitguide/mcaidread_tool2_readm_review.docx
     June 02, 2025 - Rather than looking for the one reason for the readmission, capture all the factors that contributed … Analysis and Lessons Learned (2-3 minutes each) The purpose of a root cause analysis is to understand the factors … If those are factors, ask “why” again. … Specifically seek to identify clinical, behavioral, social, and logistical factors that might have contributed

322. Final Progress Report: Unexpected Clinical Events: Impact on Patient Safety (pdf file)
     www.ahrq.gov/sites/default/files/2024-12/weinger2-report.pdf
     January 01, 2024 - Human factors research in other high-risk fields has demonstrated how rigorous study of factors that … The decision to extubate a patient is complex, involving multiple factors 26. … factors affecting clinical task performance and decision-making. … Proceedings of the Human Factors and Ergonomics Society 2004; 48: 1746-1750. … Human Factors and Ergonomics Society.

323. Roadmap for Implementing Pediatric Quality Measures for Performance Improvement | Agency for Healthcare Research and Quality
     www.ahrq.gov/pqmp/implementation-qi/roadmap/index.html
     September 01, 2021 - follow the steps to explore the measure implementation process, including understanding contextual factors … Having an awareness and understanding of the contextual factors that may be at play, before initiating … order to better understand your context, see the link below to a self-study exercise on contextual factors … Success in Quality (MUSIQ), which is a conceptual model for understanding and optimizing contextual factors … Example: PQMP IMPLEMENT Team Self-study Exercise on Contextual Factors Using the MUSIQ Framework

324. Healthcare Safety Competencies Affinity Group | Agency for Healthcare Research and Quality
     www.ahrq.gov/action-alliance/competencies-affinity-group/index.html
     May 01, 2025 - Communication Processes  Detecting and Mitigating Safety Risks  Disclosure  High Reliability  Human Factors … Engineering (Human-Centered Design) Individual Factors/Individual Failure Modes Responding to Safety … Events—Immediate Actions and Longer-Term/Systemic Follow-up  Safety Reporting  Situational Awareness Systems Factors

325. Methods and Metrics Issues in Delivery Systems Research
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/system/delivery-system-initiative/alexander/alexander.pptx
     February 16, 2011 - 3 Manner in which a given DSC is implemented and practiced is influenced by range of factors surrounding … the specific change These factors constitute the social system or social context of change These factors … Fidelity and sustainability follow from interrelationships among a range of internal and external factors

326. Sensemaking and Learn from Defects for Perinatal Safety (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.pdf
     May 01, 2017 - Visualize the factors that led to the event. • Step 2. Identify the contributing factors. … Prioritize the contributing factors. 3. What will you do to reduce the risk of recurrence? … Develop interventions for two to five of the most important factors. … sometimes look at the technical factors. … by human factors.

327. Reducing Waste and Inefficiency in Health Care Through Lean Process Redesign: Literature Review | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/leanprocess/leanprocess.html
     May 01, 2018 - If so, the goal is to identify the organizational and contextual factors that may systematically contribute … To guide our efforts, we first developed a framework of the factors likely to affect Lean implementation … These factors include contextual (organizational and environmental) variables, as well as variables associated … For example, there was little rigorous reporting about external impetus for Lean/TPS (e.g., market factors … ), organizational factors (e.g., how culture affects who implements Lean/TPS), outcomes (e.g., financial

328. 2. Priority Questions and Recommendations | Agency for Healthcare Research and Quality
     www.ahrq.gov/prevention/resources/chronic-care/clinical-community-relationships-eval-roadmap/ccre-roadmap2.html
     July 01, 2013 - In fact, the relative influence of factors is generally expected to vary according to the particular … Little is definitively known, however, about how the relative influence or importance of the factors … Future research that elucidates the circumstances under which the basic six factors are most important … What are the factors that can motivate clinical and community organizations to form relationships for … Within each of these six basic factors, multiple measures could relate to numerous different domains.

329. AHRQ Final Progress Report: Developing an Integrated Engineering-Based Model to Reduce Infections in the ICU (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/mastrangelo-report.pdf
     January 01, 2024 - Risk analysis is then utilized to evaluate the effect of different patient physiological factors and … The framework is flexible and can accommodate additional factors that may be discovered in the future … A variety of factors, e.g., patient physiological attributes and medical functions performed on the … For this environment, the study mechanism should enable assessment of the effect of different factors … Different factors affecting the spread of HA infections are identified in the literature.

330. Falls Prevention Self-Assessment Worksheet - AHRQ’s Safety Program for Nursing Homes: On-Time Falls Prevention (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/ontimefallspxselfassessment.pdf
     June 02, 2025 - • Develop interventions specific to the risk factors to mitigate falls risk. … If yes, does the policy include the following: Yes No Examination of clinical risk factors (e.g., … Do falls prevention care plans include interventions addressing the following falls risk factors? … familiarity with environment   Recent hospitalization or change in condition   Environmental factors … Can you determine if the fall was due to clinical factors (e.g., change in resident risk factors, inadequate

331. AHRQ Safety Program for MRSA Prevention: Targeting SSI
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/125-cusp-science-safety.pptx
     April 01, 2025 - 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 reviews of these factors improves patient safety; the Comprehensive Unit-based Safety … What are some of the system factors that contributed to Marta’s rehospitalization and SSI? … Consider all factors, or holes in the system, that led to this outcome.

332. Chapter 3. Outline the Evidence and Identify Best Practices | Agency for Healthcare Research and Quality
     www.ahrq.gov/es/patient-safety/settings/hospital/vtguide/guide3.html
     February 01, 2016 - longer acutely ill, and fully ambulatory patients not at risk for VTE or without multiple VTE risk factors … VTE in patients having nonorthopedic surgery depends on both patient-specific and procedure-specific factors … Comorbidities or complicating factors may delay hip fracture repair, and starting LMWH between admission … Age, obesity, and comorbidities such as infection and pulmonary disease are additive risk factors, just … as an elevated platelet count or leukocyte count or hemoglobin <10 g/dL, are also cited as VTE risk factors

333. Chapter 3. Outline the Evidence and Identify Best Practices | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/vtguide/guide3.html
     February 01, 2016 - longer acutely ill, and fully ambulatory patients not at risk for VTE or without multiple VTE risk factors … VTE in patients having nonorthopedic surgery depends on both patient-specific and procedure-specific factors … Comorbidities or complicating factors may delay hip fracture repair, and starting LMWH between admission … Age, obesity, and comorbidities such as infection and pulmonary disease are additive risk factors, just … as an elevated platelet count or leukocyte count or hemoglobin <10 g/dL, are also cited as VTE risk factors

334. Using Root Cause Analysis to Help Practices Understand and Improve Their Performance and Outcomes (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/ncepcr/tools/PCMH/pcpf-module-11-root-cause-analysis.pdf
     December 27, 2021 - Use the “5 Whys” process with a group to identify factors that contribute to less-than-optimal performance … Use a fishbone diagram (also called a cause-and-effect diagram) to identify factors that contribute … It can be a good way to get an individual or group thinking more deeply about the factors underlying … It is one thing to have leadership or quality improvement team members imagine or guess which factors … Ask participants to brainstorm factors that may be causing the problem within each category.

335. Special Considerations for Measurement of Diagnostic Safety | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/state-of-science-2.html
     June 01, 2020 - conceptualized as events that may be distributed over time and place and shaped by multiple contextual factors … complex dynamics involving system-related, patient-related, team-related, and individual cognitive factors … Subspecialty and referral-specific factors. … Patient-related factors. 24 Diagnostic performance is the outcome of these processes within a complex … affecting diagnostic performance and measurement, such as payment systems, legal factors, national quality

336. Section 6B (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/outcomes/chipra-140-section-6-b.pdf
     June 02, 2025 - Uniqueness indicates the percentage of variation in this variable that is not explained by any of the other factors

337. Appendix G. Readiness Assessment | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/clabsi-final-companion/clabsicompapg.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.

338. Engineering Safety into Practice through Implementation of the 2025 SAFER Guides - Slide Presentation (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/action-alliance/safer-guides-slides.pdf
     February 18, 2025 - concerns before harm 10 The Need for Proactive Risk Assessment • HHS-sponsored “Safety Assurance Factors … practices: ► Focused on high-risk areas ► All guides freely available 11 SAFER: Safety Assurance Factors … from clinical medicine, patient safety, informatics, quality improvement, risk management, human factors … committee or expand existing committees to include: ► Data scientists, informaticians, AI experts, human factors … Harm EHR Safety Defined: 3 domains The Need for Proactive Risk Assessment SAFER: Safety Assurance Factors

339. Changing-System-Facilitator-Guide (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/changing-system-facilitator-guide.docx
     June 01, 2021 - . · List factors that may compromise patient safety. · Develop an intervention to reduce problems and … Negative contributing factors are those that caused harm or almost caused harm. … These are factors you want to change. In this case, negative contributing factors were: 1. … Positive contributing factors are those that limit or prevent harm. … In this case, positive contributing factors included— 1.

340. Final Progress Report: How Do Consumers View the Risks of Medical Errors? (pdf file)
     www.ahrq.gov/sites/default/files/2024-07/peters-report.pdf
     January 01, 2024 - defined by individuals influenced by a wide array of psychological, social, institutional, and cultural factors … However, participants were unable to identify factors critical to preventing errors in a hospital; they … individuals who may be influenced by a wide array of psychological, social, institutional, and cultural factors … In particular, past results lead us to expect two factors: one factor related to the dreadedness of … In a factor analysis of perceived risk characteristics of medical errors, two factors emerged.