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Showing results for "factors".

341. 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.

342. 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

343. 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.

344. 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.

345. 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

346. EvidenceNOW: Ohio Cooperative (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/building-capacity/EvidenceNOW-BSC-OH-profile.pdf
     September 01, 2021 - The state has a high burden of cardiovascular disease (CVD) and substantial disparities in CVD risk factors … Smoking rates are higher in Ohio’s geographic regions with lower socioeconomic factors mirroring the … Determine patient, provider, clinic, and other contextual factors associated with greater improvements … implementation, maintenance, and efectiveness of the heart healthy QIP overall and by subgroup; and (3) factors

347. Appendix C. Data Dictionary | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/ssi/ssiapc.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.

348. Presentation: Program Overview
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/cusp/science-of-safety-slides.pptx
     January 01, 2017 - After this session, you will be able to— Understand and apply the Science of Safety Identify how system factors … Science of Safety ‹#› AHRQ Safety Program for Mechanically Ventilated Patients 5 Institutional System Factors … Program for Mechanically Ventilated Patients 6 Safety Institutional Hospital Departmental Factors … Work Environment Team Factors Individual Provider Task Factors Patient Characteristics

349. Appendix F. Team Checkup Tools | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/cusp/clabsi-final-companion/clabsicompapf.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.

350. 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

351. NPSD Data Spotlights | Agency for Healthcare Research and Quality
     www.ahrq.gov/npsd/data/spotlights.html
     September 01, 2025 - Falls: Associated Factors and Clinical Outcomes (PDF, 4.6 MB) examines clinical outcomes and factors

352. Final Progress Report: Evaluating safety and quality of tracheal intubation in pediatric ICUs (pdf file)
     www.ahrq.gov/sites/default/files/2025-02/nishisaki2-report.pdf
     January 01, 2025 - To identify candidate factors to target for pediatric TI quality improvement by analyzing NEAR4KIDs … Risk factors included pre-existing hemodynamic instability, history of difficult airway, and resident … Risk factors were identified. … A preliminary QI checklist was developed by incorporating the identified risk factors (factors associated … First, clinical variables were evaluated for potential risk factors for TIAEs and severe TIAEs.

353. AHRQ Grant Final Progress Report: Improving Patient Safety Through Provider Communication Strategy Enhancements (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/daugherty-report.pdf
     January 01, 2024 - science.3 Human factors related to cognitive overload; the effects of stress, fatigue, distractions … Team factors made up 21% of the contributing factors to the total patient safety occurrences, as reported … Team factors 1418 20.9% 1170 20.6% 2. Work environment 1646 24.3% 1326 23.4% 3. … Task factors 1995 29.5% 1608 28.3% 4. Staff factors 204 3.1% 161 2.8% 5. … : team factors, 2004-2005 Team Factors 2004 Risk Manager Score Percent 2005 Risk Manager Score

354. Improving Diagnosis in Emergency and Acute Care: A Learning Laboratory (IDEA-LL) | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/resources/learning-lab/idea-ll-long-desc.html
     August 01, 2025 - emergency departments (EDs) by examining diagnostic decision making, identifying contributing risk factors … Through a transdisciplinary team of clinicians, engineers, human factors experts, informaticians, and … decision-making processes in the ED and identify contributing patient-, provider-, and system-level factors … Investigating Factors Influencing Diagnostic Safety in Emergency Department Patients Using Decision Trees … Mining Electronic Health Records To Identify Key Factors Influencing Diagnostic Errors in the Emergency

355. The Contribution of Diagnostic Errors to Maternal Morbidity and Mortality During and Immediately After Childbirth: State of the Science (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/dxsafety-issuebrief-maternal-morbidity.pdf
     September 01, 2021 - ].15 Cognitive and system errors are major contributing factors to diagnostic error. … delayed diagnosis.19 System errors are major contributing factors to diagnostic error. … Explore teamwork factors associated with prompt response to [maternal hemorrhage]. … Explore which factors promote real-time quantification and discussion of blood loss. … The continuum of maternal morbidity and mortality: factors associated with severity.

356. 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.

357. 089-Or-Traffic-Fg (doc file)
     www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/089-or-traffic-fg.docx
     April 01, 2025 - This presentation will review components of the OR airflow, or ventilation, and explore how these factors … Slide 8 Human Factors Engineering SAY: Multifactorial processes can affect OR air quality, and the … Here are two examples using human factors engineering or understanding and working within the way work … Another example of applying human factors engineering comes from the Netherlands. … and examined the system factors that could have contributed to the event—in this case, increased door

358. PS Grantee | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/index.html?page=2
     January 01, 2024 - These topics include human factors approaches to improve patient safety, patient safety measure development … Grant Number: P30 HS 024380 Topic(s): Healthcare Facility Design, Human Factors Approaches To Improve … Grant Number: R18 HS 023754 Topic(s): Medication Safety Publication Date: June 2021 Factors … Principal Investigators: James, et al Grant Number: R01 HS 25965 Topic(s): Human and Environmental Factors

359. PS Grantee | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/index.html?page=6
     January 01, 2024 - These topics include human factors approaches to improve patient safety, patient safety measure development … Investigators: Kellogg Grant Number: R03 HS 024801 Topic(s): Emergency Care, Human and Environmental Factors … ) Principal Investigators: Wilson Grant Number: R03 HS 024607 Topic(s): Human and Environmental Factors … Investigators: Trowbridge Grant Number: R13 HS 024883 Topic(s): Conference, Diagnostic Safety, Human Factors

360. PS Grantee | Agency for Healthcare Research and Quality
     www.ahrq.gov/research/findings/final-reports/index.html?page=9
     January 01, 2024 - These topics include human factors approaches to improve patient safety, patient safety measure development … 12 13 14 … More pages next › ›› last » Last » Factors … Investigators: Miller and Birkmeyer Grant Number: K08 HS 018346 Topic(s): Human and Environmental Factors … Grant Number: R03 HS 021332 Topic(s): Diagnostic Safety, Human and Environmental Factors, Simulation