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www.ahrq.gov/sites/default/files/wysiwyg/chsp/CHSP-accomplishments-report-2021.pdf
January 01, 2021 - The goal was to
understand the factors that affect health systems’ use of patient-centered outcomes … • Develop measures of integration and identify how environmental factors influence the
adoption of … • Identify factors that influence the successful deployment of effective biomedical
innovations, factors … The first two
projects focused on understanding internal and external factors that drive the use of … Understanding systems’ patient factors, patient engagement, and PCOR; and
6.
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www.ahrq.gov/patient-safety/settings/hospital/resource/pressureinjury/workshop/slides3.html
October 01, 2017 - How to conduct a standardized assessment of pressure injury risk factors. … How to incorporate risk factors into care planning. … Meant to be used in conjunction with a review of other risk factors and clinical judgment. … More factors to consider. … Practices
Need to be customized:
Each patient has a different set of pressure injury risk factors
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/assess-adapt-060314.pptx
March 01, 2009 - Teams make wise decisions when there is diverse and independent input
15
Understanding System Factors … 16
Adapted from Vincent
Regional
Clinic
Work Environment
Team Factors
Individual Provider
Task … Factors
Patient Characteristics
Corporate
16
17
System Failures Leading to Error
(Reason, 1990 … Second order problem solving
Fixing the immediate problem
Fixing the system factors that allowed the … Communication failure: basic components, contributing factors, and the call for structure.
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www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-0232-table2.pdf
January 01, 2011 - Genetic, metabolic, and hormonal factors such
as insulin resistance, increased serum
aldosterone levels … Risk factors and risk behaviors accelerate the
development of atherosclerosis, and risk
reduction delays … Overweight and obesity, nutrition/diet,
physical inactivity, and blood pressure are all
factors to
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Marken.pdf
January 01, 2004 - Theories of human
error attribute errors to factors such as poor system design, but these theories do … Factors related to errors
in medication prescribing. JAMA 1997 277(4):312–17.
8. Galt KA. … Medication errors and
human factors. In: McCabe PT, editor; Contemporary
Ergonomics 2003. … To err is human factors. Technol Rev 1982
Feb/Mar:23-29.
17. Freud S. … Human Factors in Aviation.
New York: Academic Press; 1988.
21. Rubin J.
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/strat.html
October 01, 2017 - Weekly Falls Risk or Safety Meetings
Quarterly Summary of Falls Risk Factors by Unit or … Weekly Falls Risk or Safety Meetings
Monthly Contextual Factors by Unit or Facility
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/injuries/fallspx/manapb17.html
December 01, 2017 - These reasons are called fall risk factors. Many of these we can change. … Fall Risk Factors We Can Change
Residents' Living Space and Personal Safety
Clutter, uneven floors
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www.ahrq.gov/downloads/pub/prevent/pdfser/chdser.pdf
December 08, 2003 - Some of these treatments are directed at traditional risk factors (e.g.,
statins for hyperlipidemia … The presence or absence of CHD risk factors affected the cost-effectiveness ratios. … or more
CHD risk factors, it was $20,504. … The Italian RIFLE Pooling Project
(Risk Factors and Life Expectancy). … Exercise-enhanced assessment of risk factors for coronary heart
disease in healthy men.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/modules/onboarding/onboarding_scienceofsafety_facnotes.docx
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
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/public-reporting/report-1-public-reporting.pdf
June 01, 2010 - Humans can
only integrate a limited number of factors into a choice. … Making tradeoffs among different categories of factors (e.g., a doctor who communicates well
but whose … Differential weighting of factors in a choice is problematic for people. … Consumers must process
a large amount of information, select relevant factors and differentially weight … them, and bring
all the factors together into a choice.
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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-Seagull_98.pdf
April 07, 2008 - patient safety: (1) surgical simulation, (2) “smart image,”
(3) informatics, and (4) ergonomics/human factors … Ergonomics and human
factors are used to design physical and informational workplaces for better outcomes … Ergonomics often focuses on the physical
environment and the human body, while human factors center … Applying human factors to information systems can ensure their
usability. … The importance of
human factors in the operating room. Anesthesiology
1994; 80(2): 479.
25.
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www.ahrq.gov/hai/cusp/modules/identify/notes.html
December 01, 2012 - Discuss the three greatest risks, and
Rank these risk factors. … Visualize the factors that led to the event.
Step 2. Identify the contributing factors.
Step 3. … Develop interventions for two to five of the most important factors.
Step 2. … look at the technical factors. … by human factors.
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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-Perry_49.pdf
March 27, 2008 - In contrast, human factors specialists express
concern about potential unintended consequences of this … approach, particularly when it is applied
across a wide variety of practitioners and settings, due to factors … The downside is the lack of requisite expertise from human
factors engineering, which might result in … Communication failure: Basic
components, contributing factors, and the call for
structure. … Int J Hum Factors Manufact 1995; 5: 163-176.
29. Matthews AL, Harvey CM, Schuster RJ, et al.
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www.ahrq.gov/hai/tools/mvp/modules/technical/head-bed-elevation-lit-review.html
January 01, 2017 - Study findings showed four factors to be independently associated with VAP: an organ system failure index … that the supine position and length of time the patient is kept in this position are potential risk factors … Grap, 2010) 13
Clinical review: This review summarizes the epidemiology, pathophysiology, and risk factors … Stepwise logistic regression analysis identified four factors to be independently associated with VAP … Stepwise logistic regression analysis identified four factors to be independently associated with VAP
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/head-bed-elevation-litreview.docx
January 01, 2017 - Study findings showed four factors to be independently associated with VAP: an organ system failure index … that the supine position and length of time the patient is kept in this position are potential risk factors … (Grap, 2010)13
Clinical review: This review summarizes the epidemiology, pathophysiology, and risk factors … Stepwise logistic regression analysis identified four factors to be independently associated with VAP … Stepwise logistic regression analysis identified four factors to be independently associated with VAP
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/cauti-ltc/modules/resources/tools/cauti-surveillance/review-form.docx
March 01, 2017 - This form is designed to identify contributing factors to and the root cause of a CAUTI that meets the … , if applicable: _________________ Antibiotic(s): __________________ Sensitive: Y – N
Contributing Factors … Using the responses to contributing factors above, what contributed to the resident developing a CAUTI
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www.ahrq.gov/ncepcr/care/coordination/atlas/chapter6c.html
June 01, 2014 - professionals to synergistically influence the patient care provided.” 1 The instrument focuses on 2 factors … Factor analysis confirmed the presence of two distinct factors measuring unique components of collaboration … or Health System Characteristics: Measure developers indicate that further testing of theory-linked factors … Factor analysis confirmed the presence of two distinct factors measuring unique components of collaboration … or Health System Characteristics: Measure developers indicate that further testing of theory-linked factors
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www.ahrq.gov/prevention/resources/chronic-care/clinical-community-relationships-eval-roadmap/ccre-roadmap1.html
July 01, 2013 - the Clinical-Community Relationships Measures Atlas ( Dymek et al., 2013 ), we pair the six basic factors … In addition, the relevance and influence of different factors will vary according to the particular clinical … In recognition of wide local variations in myriad influential factors, the expert panel strongly emphasized … Hence, it is critical that contextual factors are considered in the design, implementation, and evaluation … important to conduct rich qualitative research that elucidates the nature and influence of the contextual factors
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www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/sustainability/guide.html
March 01, 2017 - This how-to guide is organized into short sections on critical factors to successfully improve and sustain … It provides recommendations, tools, and resources to ensure that the success factors for improving and … Key factors contributing to the failure of HAI reduction efforts over time include not educating new … safety for nursing home residents. 3
More importantly, research has identified six critical success factors … Critical success factors for performance improvement programs.
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www.ahrq.gov/sites/default/files/wysiwyg/nhguide/5_TK2_T1-Concise_Antibiogram_Toolkit_Background.pdf
May 01, 2014 - Antibiograms provide guidance for empiric antibiotic use in patients, but other factors
including … patient characteristics and prevalence of other risk factors should be
incorporated when making therapeutic