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www.ahrq.gov/chsp/about-chsp/centers-of-excellence/rand.html
August 01, 2017 - understanding of the complex structures of health systems, as well as the many contextual and environmental factors … How do market factors (e.g., the competitiveness of the local health care market) influence health system … about daily practice; what the chief barriers and facilitators to PCOR uptake are; and what contextual factors … manager and staff surveys, the team is measuring organizational and clinical integration and contextual factors … systems in our four study regions to assess the relationships between contextual and organizational factors
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www.ahrq.gov/policymakers/chipra/statesummaries/co-spotlight.html
July 01, 2015 - Developed an electronic questionnaire that screens adolescents for social and behavioral risk factors … SBHC staff indicated that the electronic screener helped to identify risk factors that required followup … SBHCs also reported that aggregating the screening data helped them identify the risk factors common … The screeners produced important information on youth’s social and behavioral health-related risk factors … One SBHC decided to continue using a previously implemented screener to assess adolescent risk factors
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www.ahrq.gov/hai/cusp/clabsi-final-companion/clabsicompapd.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.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Galt.pdf
January 01, 2004 - All factors were
retained with an Eigen value greater than 1. … The factors were displayed using a score
coefficient matrix. … A factor score was calculated for each of the factors identified. … It is labeled “no human factors limitations with computing
devices.” … The factors that emerged in this study are consistent with this notion.
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www.ahrq.gov/sites/default/files/publications/files/execsumm-lean-redesign.docx
March 01, 2017 - of Lean redesigns as an organizationwide initiative, with a particular focus on analyzing contextual factors … Our analysis focused on contextual factors and processes affecting the spread and sustainability of this … We also looked at which key contextual factors affected the acceptance and adoption of Lean redesigns … , how these contextual factors affected frontline acceptance of Lean practices. … These factors include the implementation approach; characteristics of the inner setting (e.g., local
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www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxchecklists-2.html
September 01, 2020 - Reduction
Introduction
Rationale for Use
Content-Specific Versus Process-Focused Checklists
Factors … We will discuss the evidence for the effectiveness of checklists for diagnostic error reduction and factors
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www.ahrq.gov/hai/cusp/videos/index.html
September 01, 2019 - Identifying Contributing Factors
What Will You Do to Reduce the Risk of Recurrence? … Manager as a Mentor and Coach
Encourage Professional Development of Staff
Work Alignment
Spread
Factors
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www.ahrq.gov/sites/default/files/2024-01/arbaje-report.pdf
January 01, 2024 - Improving Care Transitions across Healthcare
Settings through a Human Factors Approach. … Carayon P, ed Handbook of Human Factors and Ergonomics in Health Care and Patient
Safety. … Time to accelerate integration of human factors and
ergonomics in patient safety. … Human factors systems approach
to healthcare quality and patient safety. … Improving Care Transitions Across Healthcare
Settings Through a Human Factors Approach.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_scienceofsafety_training.pptx
December 01, 2017 - Impact Safety5
Hospital
Departmental Factors
Work Environment
Team Factors
Individual Provider … Task Factors
Patient Characteristics
Institutional
Science of
Improving Patient Safety … It shows the continuum of system factors that can influence health care delivery and the occurrence of … We need to consider these factors when we respond to defects or otherwise make desired changes. … These factors range from hospital and institutional factors such as facilities and budgetary constraints
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www.ahrq.gov/patient-safety/reports/candor-demo-program/plan-grants/findings.html
August 01, 2022 - and using old prescriptions, and problems with access to medications) and health system factors (poor … In the assessment of the factors involved in pregnancy-associated and pregnancy-related deaths, the top … three individual factors identified were chronic medical conditions, substance abuse, and delay and/ … or failure to seek care; the top three system factors were lack of case coordination and management, … poor patient–provider communication, and lack of continuity of care; and the top three clinical factors
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/clabsi-cauti-icu/clabsi-learning-from-defects_revised.docx
April 01, 2022 - This worksheet will help your team learn what happened, identify the factors that may have contributed … What factors contributed? … Yes No Uncertain
12) Anything else, patient factors or otherwise, that may have
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/best-practices/HAP-one-page.docx
November 01, 2019 - cultures have been obtained, de-escalate therapy based on clinical judgment and individual patient risk factors … oral medications can be tolerated, consider conversion from intravenous to oral therapy
· If no risk factors … Risk factors for methicillin-resistant Staphylococcus aureus in patients with community-onset and hospital-onset
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www.ahrq.gov/hai/tools/surgery/modules/sustainability/learn-from-defects-slides.html
December 01, 2017 - Develop a “system perspective” to see the hidden factors that led to the event. … List all contributing factors and identify whether they harmed or protected the patient. … Prioritize most important contributing factors and most beneficial interventions. … Image: A grid matrix to prioritize contributing factors. … Prioritize contributing factors and interventions.
Use safe design principles.
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www.ahrq.gov/sites/default/files/2024-01/noskin-report.pdf
January 01, 2024 - An assessment of
medication-related risk factors was performed on 428 patients. … No other potential risk factors for medication
discrepancies were noted to be significant. … (4) To identify risk factors frequently responsible for inaccurate medication
reconciliation. … An assessment of medication-related risk factors was performed on 428
patients (65.7%). … No other potential risk factors for medication discrepancies were
noted to be significant.
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www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/20131008_cg/1_Carla_Zema_Intro_slides_1-23.pdf
October 08, 2013 - • Clerks and receptionists treat you with
courtesy and respect
CG-CAHPS Survey Versions
Factors … • Further research and testing are needed to
develop lower cost methods of data collection
Factors … Clinician & Group Surveys (CG-CAHPS)
CAHPS Surveys
CG-CAHPS Core Measures
CG-CAHPS Survey Versions
Factors … an illustration
Psychometric Properties
Visit Survey Percentile Distributions
Implications
Factors
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www.ahrq.gov/patient-safety/resources/learning-lab/owll-long-desc.html
August 01, 2025 - The specific aims were to: 1 Identify and understand the contributing factors behind common dental AEs … Identifying contributing factors associated with dental adverse events through a pragmatic electronic … Identifying contributing factors associated with dental adverse events through a pragmatic electronic
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www.ahrq.gov/research/findings/final-reports/stpra/stpra2.html
April 01, 2018 - gleaned through four unique and important quantitative and qualitative data sources:
Known risk factors … , and human factors, in the risk model. … The process mapped by a ST-PRA model incorporates factors that are internal to the process and factors … of factors that are related to institutions or to the system. … To ensure that ST-PRA captures all possible process factors, it is important to scour several sources
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Drews_15.pdf
February 26, 2008 - Despite the impact of these errors,
little research has identified the human factors that contribute … The current
study uses the error-producing conditions (EPC) approach to help identify device-related factors … Thus,
EPCs can be thought of as additional factors that increase the probability of error. … Williams
conceptualized them as factors that have a consistent effect on human reliability. … Device-related EPCs in general shed some light on the contributing factors to error in the ICU.
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www.ahrq.gov/prevention/guidelines/tobacco/clinicians/presentations/2008update-full/slide125.html
October 01, 2014 - What other factors may influence medication selection? … Pragmatic factors may also influence selection such as insurance coverage or out of pocket patient costs
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www.ahrq.gov/sites/default/files/wysiwyg/npsd/data/npsd-falls-chartbook-2023.pdf
January 01, 2023 - Source:
NPSD Data Spotlight, Falls: Associated Factors and Clinical Outcomes, 2023. … Risk Factors by Patient Age
The figures below display RISK FACTORS by PATIENT AGE. … Counts
were taken where valid, non-missing information was available for RISK FACTORS and
PATIENT … Risk factors can impact the occurrence and outcome of Fall Incidents. … were excluded.
31
APPENDIX B - TECHNICAL NOTES FOR ANALYSES PRESENTED IN FOCUS: RISK
FACTORS