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www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit3-20.html
November 01, 2014 - Major Factors that Inhibit Lean Success
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Table of Contents
Improving
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa/162-example-completed-learning-defects-tool.docx
October 01, 2024 - Positive contributing factors limited the amount of harm. … Rate the most important contributing factors that relate to the incident.
III. … Negative contributing factors are factors that harmed or increased the risk of harm for patients. … Positive contributing factors are factors that limited the impact of harm for patients. … Factors
Negative Contributing Factors
Positive Contributing Factors
Patient Factors (related to clinical
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www.ahrq.gov/chsp/about-chsp/centers-of-excellence/dartmouth.html
August 01, 2017 - Develop measures of integration and identify how environmental factors influence the adoption of new … Identify factors that influence the successful deployment of effective biomedical innovations, factors … Evaluate factors that influence decisions to adopt health care delivery innovations and identify ways … Identify factors that influence the adoption of innovations that enhance patient engagement or promote … Study how the influence of these factors varies across different types of organizations.
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www.ahrq.gov/research/findings/final-reports/ssi/ssiaps.html
April 01, 2018 - Initial Risk Factors
Appendix J. Additional Risk Factors
Appendix K. … Final Risk Factors
Appendix L. … , they agreed that many presumed risk factors may prove unimportant. … the identification of evidence-based risk factors for SSI. … Further research to identify evidence-based risk factors for SSI is needed.
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www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/resources/tools/cauti-surveillance/review-form.html
March 01, 2017 - This form is designed to identify contributing factors to and the root cause of a CAUTI that meets the … 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/sites/default/files/wysiwyg/npsd/Medication_Dashboard_Data_2025.xlsx
January 01, 2025 - Action - Incidents Med_4
Stage of Origin by Incorrect Action - Incidents Med_5
Contributing Factors … by Incorrect Action - Incidents Med_6
Contributing Factors Known by Patient Age - Incidents … Med_7
Contributing Factors by Patient Age - Incidents Med_8
Incident Preventability by Patient … Age - Incidents Med_9
Stage of Origin by Incorrect Action - Near Misses Med_10
Contributing Factors … Med_6
Med_6: Contributing Factors by Incorrect Action - Incidents
Incorrect Action(s) Contributing
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www.ahrq.gov/research/findings/final-reports/ssi/ssiapq.html
April 01, 2018 - Initial Risk Factors
Appendix J. Additional Risk Factors
Appendix K. … Final Risk Factors
Appendix L. … A risk model should be based on patient factors as predictors. … Factors, Risks, and Rates
The specific definition of a factor is important. … of rates based on end results (outcome factors).
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www.ahrq.gov/sites/default/files/wysiwyg/npsd/Medication_Dashboard_Data_2024.xlsx
January 01, 2024 - Action - Incidents Med_4
Stage of Origin by Incorrect Action - Incidents Med_5
Contributing Factors … by Incorrect Action - Incidents Med_6
Contributing Factors Known by Patient Age - Incidents … Med_7
Contributing Factors by Patient Age - Incidents Med_8
Incident Preventability by Patient … Med_6
Med_6: Contributing Factors by Incorrect Action - Incidents
Incorrect Action(s) Contributing … Factors for Event Frequency Percent
Adult (18-64 years) No 3,767 7.4%
Adult (18-64 years) Unknown
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/fallspx/slides.html
November 01, 2017 - Prevention Electronic Reports
Electronic Reports
Falls High-Risk Report
Summary of Fall Risk Factors … (by Unit or Facility)
Contextual Factors Report (by Unit or Facility)
Postfall Assessment Report … What are the most common risk factors?
Which acute change was seen most often? Least often? … Report can be used to monitor overall prevalence and trends of risk factors associated with falls on … Slide 26: Summary of Falls Risk Factors Report Calculation Details
Displays the following data:
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www.ahrq.gov/research/findings/final-reports/index.html?page=18
January 01, 2024 - These topics include human factors approaches to improve patient safety, patient safety measure development … Grant Number: UC1 HS 014376 Topic(s): Human and Environmental Factors, Human Factors Approaches To … Grant Number: R01 HS 011963 Topic(s): Human and Environmental Factors, Human Factors Approaches To … , Human Factors Approaches To Improve Patient Safety Publication Date: September 2005
Weekend … Grant Number: R03 HS 014073 Topic(s): Human and Environmental Factors Publication Date: September
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www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/mrsa-2/130-ss-swiss-cheese-fg.docx
April 01, 2025 - Many factors can impact patient care. … Task factors involve task design and task clarity. A task or an order may be unclear. … Additionally, team-level factors may influence patient outcomes. … Slide 11
System Factors—3
SAY:
There were also team factors, related to team structure and communication … Slide 12
System Factors—4
SAY:
There were also department-level factors.
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www.ahrq.gov/hai/tools/surgery/tools/applying-cusp/learn-from-defects.html
December 01, 2017 - Harmful contributing factors contribute to patient harm; protective factors contribute to patient safety …
Individual provider factors
Team factors …
Hospital factors
Institutional factors
… Focus your efforts on the most important contributing factors. … Harmful contributing factors contribute to patient harm; protective factors contribute to patient safety
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www.ahrq.gov/hai/cusp/modules/understand/alt-text.html
July 01, 2018 - Slide 7
System-Level Factors Affect Safety9
Concentric circles show the layered system-level factors … that affect patient safety: institutional factors, hospital factors, departmental factors, work environment … factors, team factors, individual provider factors, and task factors all have an effect on patient safety … , hospital factors, departmental factors, work environment factors, team factors, individual provider … factors, and task factors all have an effect on patient safety.
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www.ahrq.gov/hai/tools/mvp/modules/cusp/learn-from-defects-slides.html
February 01, 2017 - Slide 16: System Factors Impact Safety 2
Image: Many system factors impact safety. … : institutional, hospital, departmental factors, work environment, team factors, individual provider, … task factors, and patient characteristics.
2. … Slide 18: LFD Tool Contributing Factors
Image: Screen capture of LFD tool highlighting team factors … environment as contributing factors.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/fallsprev/ontimefallpxreports-ig.pdf
June 02, 2025 - Contextual Factors Report (by Unit or Facility). … Report
Slide 25: Summary of Falls Risk Factors Report
Slide 26: Summary of Falls Risk Factors Report … Factors Report Quiz
Slide 31: Contextual Factors Report
Slide 32: Contextual Factors Report
Slide … 33: Sample Facility-Level Contextual Factors Report by Month
Slide 34: Contextual Factors Report Calculation … Details
Slide 35: Sample Contextual Factors Graph
Slide 36: Check Your Understanding: Contextual Factors
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www.ahrq.gov/practiceimprovement/systemdesign/leancasestudies/lean-exhibit4-19.html
November 01, 2014 - Major Factors that Inhibit Lean Success
Previous Page Next Page
Table of Contents
Improving
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www.ahrq.gov/sites/default/files/2024-04/baernholdt-report.pdf
January 01, 2024 - Studies have examined factors that improve
or hinder HACs, including PUR and FR. … on the longitudinal influence of
contextual factors on PUR and FR. … This study includes contextual factors
conceptualized as the nurse work environment (NWE) factors (staffing … care interventions
that are all contextual factors included in the current study. … Payment policies that optimize these contextual factors would be a logical next step.
4.
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www.ahrq.gov/research/findings/final-reports/ssi/index.html
April 01, 2018 - Initial Risk Factors
Appendix J. Additional Risk Factors
Appendix K. … Final Risk Factors
Appendix L. … Focus Group Risk Factors
Appendix Q. Surgeon Focus Group Content Analysis
Appendix R. … Initial Risk Factors
Appendix J. Additional Risk Factors
Appendix K. … Final Risk Factors
Appendix L. Master Risk Factors
Appendix M.
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www.ahrq.gov/research/findings/final-reports/index.html?page=0
September 01, 2024 - These topics include human factors approaches to improve patient safety, patient safety measure development … Grant Number: R01 HS 025752 Topic(s): Diagnostic Safety, Emergency Care, Human and Environmental Factors … Investigators: Evans Grant Number: R01 HS 028340 Topic(s): Emergency Care, Human and Environmental Factors … et al, Grant Number: R18 HS 027259 Topic(s): Care Coordination, Communication and Teamwork, Human Factors … Safety, Older Adults, Patient Safety Learning Laboratory Publication Date: July 2023
Human Factors
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www.ahrq.gov/research/findings/final-reports/index.html
September 01, 2024 - These topics include human factors approaches to improve patient safety, patient safety measure development … Grant Number: R01 HS 025752 Topic(s): Diagnostic Safety, Emergency Care, Human and Environmental Factors … Investigators: Evans Grant Number: R01 HS 028340 Topic(s): Emergency Care, Human and Environmental Factors … et al, Grant Number: R18 HS 027259 Topic(s): Care Coordination, Communication and Teamwork, Human Factors … Safety, Older Adults, Patient Safety Learning Laboratory Publication Date: July 2023
Human Factors