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www.qualitymeasures.ahrq.gov/research/findings/final-reports/ssi/ssiexh14.html
April 01, 2018 - Initial Risk Factors
Appendix J. Additional Risk Factors
Appendix K. … Final Risk Factors
Appendix L. … Final data sheet submitted by each site that included the list of potential SSI risk factors and other … Focus Group Risk Factors
Appendix Q. Surgeon Focus Group Content Analysis
Appendix R.
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www.qualitymeasures.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/understand-sci-fac-guide.html
July 01, 2023 - Slide 6: System-Level Factors Affect Safety
Say:
As the illustration shows, at any given time, … there are several system factors that simultaneously influence unit culture and patient safety. … Task factors
In addition to patient characteristics, task factors can shape the delivery of care and … Team factors
Team factors may involve issues with teamwork, communication, inadequate supervision, and … Slide 7: System-Level Factors Can Predict Performance
Say:
When nurse-to-patient ratios exceed
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallpxtoolkit/fallpxtool3f.docx
January 29, 2013 - When a patient is on a medication that may cause orthostasis and has other risk factors for falls. … Use this tool in conjunction with clinical assessment and a standard assessment of fall risk factors … (e.g., Tool 3H, “Morse Fall Scale for Identifying Fall Risk Factors, or Tool 3G, ‘STRATIFY Scale for … Identifying Fall Risk Factors”) to determine a patient’s risk factors for falls, and then plan care accordingly
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www.qualitymeasures.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/fall-knowledge-test.html
January 01, 2013 - Risk factors for falls in the acute hospital include all of the following except :
Dizziness/vertigo … All patients should be assessed for fall risk factors at admission, at a change in status, after a fall … Risk factors for falls include:
Parkinson's disease.
Incontinence. … Education programs for staff should include the importance of fall prevention, risk factors for falls
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/pqmp/lessons/lessons-performance-comparisons.pdf
October 01, 2019 - Adjustments for demographic, clinical and social risk factors may be necessary to ensure that performance … The most common approaches used to account for these factors (demographic,
clinical and social) are … Performance Comparisons
10
Figure 5: Adjustments for demographic, clinical and social risk factors … ‣ When assessing performance on process measures, risk
adjustment should not include SES factors … Risk Adjustment for Socioeconomic Status or Other Sociodemographic
Factors.
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/understand/understand-facilitator-guide.docx
May 01, 2017 - Slide 5
SAY:
As the illustration shows, at any given time, there are several system factors that … Task factors
In addition to patient characteristics, task factors can shape the delivery of care and … Team factors
Team factors may involve issues with teamwork, communication, inadequate supervision, and … Departmental factors
When staffing issues, admission policies, and protocols prove to be insufficient … While these issues are the furthest removed from the patient in the diagram, these factors continually
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www.qualitymeasures.ahrq.gov/patient-safety/diagnostic-error-grants/index.html
January 01, 2021 - To combine adjudication data with data from Vizient to determine which specific factors contribute to … risks for diagnostic errors, and to use risk estimates to calculate incidence and impact of factors … breakdowns and (b) apply this new analytic tool to establish the incidence, types, and contributing factors … To identify the risk factors associated with diagnostic delays for infectious diseases that are frequently
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www.qualitymeasures.ahrq.gov/research/findings/final-reports/ssi/ssiexh8-10.html
April 01, 2018 - Initial Risk Factors
Appendix J. Additional Risk Factors
Appendix K. … Final Risk Factors
Appendix L. … Final data sheet submitted by each site that included the list of potential SSI risk factors and other … Focus Group Risk Factors
Appendix Q. Surgeon Focus Group Content Analysis
Appendix R.
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www.qualitymeasures.ahrq.gov/funding/grantee-profiles/index.html
April 01, 2024 - Founding Director, Johns Hopkins Center for Health Care Human Factors
Armstrong Institute for Patient … More >>
Human Factors in Surgery: Shifting the Paradigm on Patient Safety
Kenneth Catchpole, Ph.D … Medicine
Medical University of South Carolina “Human factors engineering in clinical settings is still … More >>
Applying Human Factors to Make it Easier for Clinicians to Do Their Jobs
Kristen E. … Senior Scientific Director
National Center for Human Factors in Healthcare
MedStar Health, Washington
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www.qualitymeasures.ahrq.gov/research/findings/final-reports/index.html?page=7
December 01, 2007 - Medication Safety
(73)
Communication and Teamwork
(29)
Patient Safety Tools
(19)
Human Factors … Implementation
(7)
Education and Training
(6)
Emergency Care
(5)
Human and Environmental Factors … These topics include human factors approaches to improve patient safety, patient safety measure development … Safety Publication Date: December 2006
Medication Error Reduction, Technologies, and Human Factors … Grant Number: UC1 HS 014253 Topic(s): Human Factors Approaches To Improve Patient Safety, Medication
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4u_combo_pdi09-postoprespfailure-bestpractices.pdf
May 17, 2016 - $77,739 in additional charges.4
Recommended Practice Details of Recommended Practice
Assess risk factors … Develop a set of risk factors for postoperative respiratory
failure and screen all patients undergoing … Recommended Practice: Assess risk factors
• Determine which pediatric patients are at increased risk … adverse events postoperatively, as well as improve
allocation of resources after surgery.5
• Some risk factors … • Additional adult risk factors that are applicable to children are:
o Smoking.
o Obesity.
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/sensemaking/learn-from-defects-facilitator-guide.docx
May 01, 2017 - Visualize the factors that led to the event.
Step 2. Identify the contributing factors.
Step 3. … Prioritize the contributing factors.
3. What will you do to reduce the risk of recurrence?
Step 1. … 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.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/fallpxtoolkit/fallpxtool5a.docx
January 29, 2013 - Include in Incident Reports
Examples of Information
Reason To Collect This Information
Reporting factors … Environmental factors
Buzzer/bell available within reach before fall
Highlight whether there is an … Patient factors
Mental state
Identify those patients most vulnerable to falls because of sedation,
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/npsd/data/spotlights/spotlight-ptsafety-and-covid-19.pdf
November 01, 2021 - ............................................................ 5
Descriptions of Other Contributing Factors … (typically categorized as Human Factors). … Analysis of 124 records for which “COVID-19” was referenced in the
Contributing Factors unstructured … Paraphrased text describing other contributing factors for a limited number of records
Type of Event … Additionally, when asked to indicate the factors contributing to the event or unsafe
condition, the
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/teamwork/understand/understand-facilitator-guide.pdf
May 01, 2017 - Task factors
In addition to patient characteristics, task
factors can shape the delivery of care and … Team factors
Team factors may involve issues with
teamwork, communication, inadequate
supervision … While these
issues are the furthest removed from the
patient in the diagram, these factors
continually … Analyzing what happened and why it
happened helps the team understand the
contributing factors and … Being aware of
these factors will help units develop
environments that facilitate communication
and
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www.qualitymeasures.ahrq.gov/patient-safety/settings/hospital/fall-prevention/toolkit/incident-reports.html
January 01, 2013 - Include in Incident Reports
Examples of Information
Reason To Collect This Information
Reporting factors … Environmental factors
Buzzer/bell available within reach before fall
Highlight whether there is an … Patient factors
Mental state
Identify those patients most vulnerable to falls because of sedation
-
www.qualitymeasures.ahrq.gov/evidencenow/projects/heart-health/about/cooperatives/nyc.html
March 01, 2021 - disease is the primary cause of death in the city, and prevalence of cardiovascular disease (CVD) risk factors … Use qualitative methods to assess factors that help and hinder practices in implementing change and achieving … ABCS-driven care
Three expert webinars on topics related to evidence-based management of CVD risk factors … practices [AcademyHealth, 2017]
Using Practice Facilitation in primary care settings to reduce risk factors … Population Health Summit, 2016]
Using Practice Facilitation in primary care settings to reduce risk factors
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www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/ncepcr/resources/job-aid-5-whys.pdf
May 17, 2021 - They can also be used to identify the factors contributing to exemplary
performance in order to replicate … 2
Fishbone Diagrams
Fishbone diagrams are another tool for helping a practice identify factors … existing category sets like this healthcare one: people,
materials, methods, measurement, environmental factors
-
www.qualitymeasures.ahrq.gov/research/findings/final-reports/ssi/ssiapo.html
April 01, 2018 - Initial Risk Factors
Appendix J. Additional Risk Factors
Appendix K. … Final Risk Factors
Appendix L. … Final data sheet submitted by each site that included the list of potential SSI risk factors and other … Focus Group Risk Factors
Appendix Q. Surgeon Focus Group Content Analysis
Appendix R. … Probe on barriers and enabling factors.
-
www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/evidencenow/building-capacity/EvidenceNOW-BSC-OH-profile.pdf
September 01, 2021 - The state
has a high burden of cardiovascular disease (CVD) and substantial disparities in
CVD risk factors … Smoking rates are higher in Ohio’s geographic regions with lower
socioeconomic factors mirroring the … Determine patient, provider, clinic, and other contextual factors associated
with greater improvements … implementation,
maintenance, and efectiveness of the heart healthy QIP overall
and by subgroup; and (3) factors