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Total Results: 3,623 records

Showing results for "factors".

441. Learning From Narratives About Diagnostic Experience | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-patients-source-understanding-dx-error-vol2-4.html
     June 01, 2023 - A third set of considerations involves the role of organizational or systemic factors that limit the … clinical encounters shows that it is often hard for patients to discern the impact of system-level factors … These factors include organizational constraints on referrals or limitations imposed by health insurers … about these effects and to promote clinician-patient dialogue that clarifies the impact of system-level factors

442. Patient Safety Executive Walkarounds (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Graham.pdf
     April 01, 2004 - • Key success factors. • Outcomes and improvements to date. … Advances in Patient Safety: Vol. 4 226 Human factors. … Action plans from walkaround findings in several cases have been linked to human factors work, which … Interest in the walkarounds program first began at a KP human factors workshop attended by Dr. … , organization and management, task factors, individual staff factors, patient factors) and assigned

443. Conceptual Paradigms of Diagnostic Quality, Safety, and Excellence | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-terminology5.html
     April 01, 2025 - approach improvement science in healthcare by introducing new ideas and methods from systems and human factors … approach retrospectively analyzes the event to attempt to establish causation, identify contributing factors … Safety-I often defines factors that contribute to adverse events as failures or errors, even if it uses … applied to diagnosis posits that healthcare delivery is a complex adaptive system, and the numerous factors … confirmation on exam or testing to exclude a more serious explanation when the patient may have risk factors

444. Diagnostic Failure: A Cognitive and Affective Approach (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Croskerry.pdf
     January 01, 2004 - Patient factors. … Team factors. … Attention should be paid to ambient conditions and any other significant extraneous factors. … It is important that they understand the main CDRs and ADRs and their determining factors. … Violation-producing factors and behaviors Table 3.

445. Menu of Implementation Strategies - 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/fallspximplstrat.pdf
     June 02, 2025 - Weekly Falls Risk or Safety Meetings Quarterly Summary of Falls Risk Factors by Unit or Facility … Weekly Falls Risk or Safety Meetings Monthly Contextual Factors by Unit or Facility 1.

446. Final Progress Report: What Is Patient Safety in the Medical Home? (pdf file)
     www.ahrq.gov/sites/default/files/2024-11/dy-report.pdf
     January 01, 2024 - Final Report For observations, we used a human factors approach and contextual inquiry, a process … The independent variables included contextual factors (e.g., ownership/size, population service) from … the PCMH practice data, implementation factors (e.g., quality improvement climate, perceptions of … teamwork, safety processes of care) from the interviews and surveys, and social network factors (e.g … Other key factors included self-efficacy and job satisfaction and quality improvement climate.

447. Final Progress Report: Brief, Risky, High-Benefit Procedures: Best Practice Model (pdf file)
     www.ahrq.gov/sites/default/files/2024-02/mackenzie-report.pdf
     January 01, 2024 - Video recording has a long history as a tool for Human Factors Research. … The additional human factors identified include communication, team performance, systems factors, and … Fine-grained analysis can include nuances of contextual and systems factors. … research, Human Factors, 39(2): 323 -328. 11. … Proc Human Factors and Ergonomics Soc Annual Meeting, 2002. 2.

448. TeamSTEPPS Research/Evidence Base: Teams in Health Care | Agency for Healthcare Research and Quality
     www.ahrq.gov/teamstepps-program/evidence-base/teams.html
     June 01, 2023 - Carayon (Ed.),  Handbook of Human Factors and Ergonomics in Health Care and Patient Safety  (pp. 259- … In  Proceedings of the Human Factors and Ergonomics Society 46th Annual Meeting . … (pp. 2069-73), Santa Monica, CA: Human Factors and Ergonomics Society. … What are the critical success factors for implementing team training in health care? 

449. Module 3: Best Practices in Pressure Injury Prevention | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/hospital/resource/pressureinjury/workshop/guide3.html
     October 01, 2017 - How to conduct a standardized assessment of pressure injury risk factors. … How to incorporate risk factors into individualized care planning. … Risk Factors for Pressure Injuries: Going Beyond Validated Instruments —AHRQ Pressure Injury Prevention … How to conduct a standardized assessment of pressure injury risk factors. … How to incorporate risk factors into care planning.

450. Physician Event Reporting: Training the Next Generation of Physicians (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Nguyen.pdf
     May 01, 2003 - exacerbate the situation, our health care system is stressed, as evidenced by additional contributing factors … around the specifics of a particular case, missing the broader context of systematic contributing factors … safety tools, however, results in a less comprehensive understanding of the unsafe situations and factors … is expected in the practice of medicine, and that errors are caused more often by latent systemic factors … Ensure students understand contributing factors The current medical curriculum must be expanded to

451. Conclusions and Next Steps | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxchecklists-6.html
     September 01, 2020 - Reduction Introduction Rationale for Use Content-Specific Versus Process-Focused Checklists Factors … diagnostic safety is still in its infancy, more indepth evaluation, including a focus on implementation factors

452. Final Progress Report: The Role of Collective Mindfulness in Delivering Reliable and Safe Perioperative Care to Neonates (pdf file)
     www.ahrq.gov/sites/default/files/2024-01/france-report.pdf
     January 01, 2024 - , NRE severity, and contributory factors at VUMC and PCH. … Human factors and cardiac surgery: A multicenter study. … Effects of performance shaping factors on human error. … Human factors research in anesthesia patient safety: Techniques to elucidate factors affecting clinical … Proc Hum Factors Ergon Soc. 2010;54:957-961. 110. Brown H, Prescott R.

453. The Science of Improving Patient Safety and Identifying Defects: Facilitator Notes | Agency for Healthcare Research and Quality
     www.ahrq.gov/hai/tools/surgery/modules/on-boarding/science-of-safety-fac-notes.html
     December 01, 2017 - 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. … By developing a systems point of view, we realize that, at any given time, multiple system factors may … These factors range from hospital and institutional factors such as facilities and budgetary constraints … Developing awareness of the factors that influence communication for both the sender and the receiver

454. Selected Best Practices and Suggestions for Improvement (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/d4f_pdi08-postophemorrhage-bestpractices.pdf
     May 16, 2016 - to $111,000) in children with this complication, even after controlling for a number of other risk factors … Recommended Practice Details of Recommended Practice Risk Factor Determination Determine which factors … Quality and Safety 2 Tool D.4f Recommended Practice: Risk Factor Determination • The following factors … surgery is appropriate.5 o Practice recommendation should be selected based on individual patient risk factors … Post-tonsillectomy hemorrhage: an assessment of risk factors.

455. Selected Best Practices and Suggestions for Improvement (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4t_combo_pdi08-postophemorrhage-bestpractices.pdf
     May 16, 2016 - to $111,000) in children with this complication, even after controlling for a number of other risk factors … Recommended Practice Details of Recommended Practice Risk Factor Determination Determine which factors … Quality and Safety 2 Tool D.4t Recommended Practice: Risk Factor Determination • The following factors … surgery is appropriate.5 o Practice recommendation should be selected based on individual patient risk factors … Post-tonsillectomy hemorrhage: an assessment of risk factors.

456. Seamless Care: Safe Patient Transitions from Hospital to Home (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Spehar.pdf
     April 18, 2004 - and had an unscheduled readmission within 30 days were interviewed to obtain their perceptions of factors … Results: Factors associated with readmissions varied by DRG. … Patient and organizational factors each contributed to unscheduled readmissions. … Patient demographic factors, including, age, race, ethnicity, marital status, discharge destination … Patient and organizational factors were found to have contributed to unscheduled readmissions.

457. Heart Healthy Ohio Initiative Charter: August 2021 (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/57-ohio-hhoi-charter.pdf
     August 01, 2021 - indicated, blood pressure control, cholesterol management, and smoking cessation)  Aim 3: Determine factors … the highest quartile for CVD morbidity and mortality and has significant disparities in CVD risk factors … evaluate the effectiveness of the co- designed intervention versus usual care; and 5) understanding factors … Finally, we will conduct a mixed methods study evaluating the factors associated with greater improvements … in CVD risk factors and disparity reductions using monthly EHR data, baseline and annual surveys, and

458. AHRQ Safety Program for Perinatal Care: Monitoring for Perinatal Safety: Under the Science of Safety
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/understand/understand-science-safety.pptx
     May 01, 2017 - and independent input 5 AHRQ Safety Program for Perinatal Care Science of Safety 5 System-Level Factors … Affect Safety6 6 AHRQ Safety Program for Perinatal Care Science of Safety 6 System-Level Factors … Can Predict Performance Examples of Impact of System-Level Factors System Factor Effect Nurse-to-patient … Communication failure: basic components, contributing factors, and the call for structure.

459. The Science of Improving Patient Safety
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/modules/understand/scisafety.pptx
     March 01, 2009 - teamwork Teams make wise decisions when there is diverse and independent input 6 6 System-Level Factors … Affect Safety9 7 7 8 Safety is a Property of the System 8 System-Level Factors Can … Predict Performance Examples of Impact of System-Level Factors System Factor Effect Daily rounds … Communication failure: basic components, contributing factors, and the call for structure.

460. Improving the Emergency Department Discharge Process | Agency for Healthcare Research and Quality
     www.ahrq.gov/patient-safety/settings/emergency-dept/discharge-process.html
     July 01, 2017 - ACTION II field-based research project, led by a team from Johns Hopkins University, to identify the factors … team summarizes what was learned from this pilot test about the characteristics and associated risk factors