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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/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/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/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/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/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
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www.ahrq.gov/sites/default/files/wysiwyg/nhguide/5_TK2_T1-Concise_Antibiogram_Toolkit_Background.doc
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
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/factraining.html
November 01, 2017 - Slide 5: Discussion
Can you think of any other examples when knowledge of risk factors might be … (by Unit or Facility)
Monthly Contextual Factors Report (by Unit or Facility)
Postfall Assessment … Some identify a profile of risk factors; others focus on a particular risk factor. … Monthly Contextual Factors Report displays facility trends by contextual factor. … Identify resident risk factors that may have caused a fall.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/improve/coordination/webinar03/logic_models.pptx
July 15, 2013 - through which it produces those outcomes
Interrelationships among intervention components
Contextual factors … What contextual factors are likely to affect the process? … more preventive care, better planned care)
Improved patient experience
Contextual and External Factors … to understand variation in implementation of FSPs
Using a logic model to explore how implementation factors … Service array / team structure
Service array
Team structure
Qualitative Analysis Reveal Implementation Factors
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www.ahrq.gov/hai/cauti-tools/archived-webinars/assess-adapt-slides.html
July 01, 2018 - make wise decisions when there is diverse and independent input
Slide 16
Understanding System Factors … Rings from inner to outer are: Patient Characteristic, Task Factors, Individual Provider, Team Factors … Second order problem solving
Fixing the immediate problem
Fixing the system factors that allowed … Communication failure: basic components, contributing factors, and the call for structure.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4c_combo_psi06-pneumothorax-bestpractices.pdf
May 20, 2016 - Identification of Patients at
Risk
Develop a process to address common iatrogenic pneumothorax
risk factors … • Consider the many factors identified in the literature that are associated with a higher risk of … These can be categorized as either patient related or procedure
related.2,13
Patient-related factors … Procedure-related factors include:
o Transthoracic needle aspiration.
o Thoracentesis. … Iatrogenic pneumothorax: etiology, incidence, and risk
factors.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/edenvironmentalscan/edenvironmentalscan.pdf
December 01, 2014 - But there is only limited understanding of such risk factors currently. … What are the risk factors for patients at high risk for discharge failure?
2. … They were also risk factors for
17 22frequent use of emergency medical services and death. … What are the risk factors for ED Discharge failure? … If it is an article about risk factors, answer the
risk factor questions.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Carayon.pdf
February 01, 2005 - show that a model with one underlying factor fits the data slightly
better than a model with three factors … results of the analysis of the scales on
environment/equipment/supplies show that three underlying factors … Design model with one
factor
272.3 73 .886 .836 .870 .616 .090 .097
Design model with three
factors … Human factors in organizational design and
management VII. Santa Monica, CA: IEA Press: 2003. … Presented
at the Human Factors and Ergonomics Society
Conference, 2004; New Orleans.
10.
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www.ahrq.gov/patient-safety/settings/hospital/resource/pressureinjury/workshop/slides5.html
October 01, 2017 - Ensure the known risk factors for pressure injuries are assessed. … Slide 40: Assessment of Care Planning
All the risk factors identified in the pressure injury risk … Tailor your approach to each patient, based on the patient’s risk factors.