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psnet.ahrq.gov/issue/risk-factors-retained-instruments-and-sponges-after-surgery
February 17, 2011 - Study
Classic
Risk factors for retained instruments and … Risk factors for retained instruments and sponges after surgery. … Risk factors for retained instruments and sponges after surgery. … October 10, 2012
Risk factors associated with incorrect surgical counts.
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psnet.ahrq.gov/issue/nontechnical-skills-pediatric-surgery-factors-influencing-operative-performance
June 12, 2008 - Commentary
Nontechnical skills in pediatric surgery: factors influencing operative … Nontechnical skills in pediatric surgery: Factors influencing operative performance. … Nontechnical skills in pediatric surgery: Factors influencing operative performance. … March 17, 2021
Relationship between operating room teamwork, contextual factors, and … November 18, 2016
View More
Related Resources
The rise of human factors
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www.ahrq.gov/research/findings/final-reports/ssi/ssi5.html
April 01, 2018 - Initial Risk Factors
Appendix J. Additional Risk Factors
Appendix K. … Final Risk Factors
Appendix L. … eight additional potential risk factors. … Thus, 41 potential risk factors were included.
E3.5.1. … different in the list of significant risk factors.
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/changes-facilitator-guide.pdf
November 01, 2019 - , technical factors, healthcare worker factors,
team factors, and institutional factors. … are
factors you want to change. … Positive contributing factors are factors that limited the
impact of harm. … ,
technical factors, health care worker factors, team
factors, and institutional factors. … worker
factors (potential lack of interest in guidelines or
advice), and team factors (no daily review
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www.ahrq.gov/research/findings/final-reports/ssi/ssi3.html
April 01, 2018 - Initial Risk Factors
Appendix J. Additional Risk Factors
Appendix K. … Final Risk Factors
Appendix L. … used by his institution to identify potential risk factors. … That initial list consisted of 88 risk factors for SSI (go to Appendix I ). … Risk factors identified from any surgical site were included in the list.
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/learning-antibiotic-adverse-events-form.docx
November 01, 2019 - For more information about negative and positive contributing factors, see the presentation, “Making … Identify the negative and positive factors associated with the adverse event. … Negative contributing factors are those that harmed or increased the risk of harm for the patient. … Positive contributing factors are those that limit the impact of harm. … Focus on 3–5 of the negative contributing factors from above and discuss how you will prevent these factors
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www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/results/research/cooperative-context.pdf
June 01, 2013 - Community
(a) What are the community factors that affected recruitment? … Health Care System
(a) What are the health care system factors that affected recruitment? … Historical Factors of Recent Events
(a) What are the historical factors or recent events that affected … Other
(a) What are the other factors that affected recruitment? … :
Other Factors:
Recruitment Experience from another Perspective:
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www.ahrq.gov/funding/grantee-profiles/grtprofile-fairbanks.html
December 01, 2023 - The Agency gave me the credibility to establish the largest human factors research center in a U.S. health … This approach is dedicated to understanding the factors, such as the work environment and technology, … A trained safety scientist and human factors engineer, Rollin J. … He has dedicated his career to applying a human factors engineering approach to healthcare systems. … of safety science and human factors engineering principles in healthcare delivery.
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www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/results/research/cooperative-context-external.pdf
January 01, 2016 - This
includes paying attention to factors that affect what happens during the study and considering … Identifying these factors will help future investigators and implementers
understand what affected the … We plan to report relevant contextual factors and how they affected important processes and outcomes. … We also leave space for you to fill in any “Other” factors that these categories might not
encompass … (e.g., partner strengths, stakeholder
relationships with practices)
Other Factors
What other factors
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/safety/changes-slides.pptx
November 01, 2019 - Making
AHRQ Safety Program for Improving Antibiotic Use – Acute Care
1
Objectives
Identify relevant factors … factors – Factors that limited the impact of harm for the patient (want to keep these)
11
Changes … Associated With Adverse Events
Five categories of factors that contribute to adverse events
Patient factors … Associated With Adverse Events
Types of factors
Health care worker factors are related to individual … Negative Contributing Factors Positive Contributing Factors
Vancomycin unnecessarily started empirically
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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/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/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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psnet.ahrq.gov/node/856584/psn-pdf
January 01, 2024 - Patient safety incidents in endoscopy: a human factors
analysis of non-procedural significant harm incidents … https://psnet.ahrq.gov/issue/patient-safety-incidents-endoscopy-human-factors-analysis-non-procedural … -
significant-harm
Understanding the influence of human factors on team and system performance can … Based on Human Factors Analysis and
Classification System coding, decision-based errors were the most … https://psnet.ahrq.gov/issue/human-factors-healthcare
https://psnet.ahrq.gov/issue/considering-human-factors-and-developing-systems-thinking-behaviours-ensure-patient-safety