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Showing results for "analyses".
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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34113/psn-pdf
    December 24, 2008 - than 235,000 records submitted by 570 participating facilities to Medmarx and also provides trend analyses

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43997/psn-pdf
    August 02, 2015 - sentinel-events-serious-reportable-events-and-root-cause-analysis This commentary describes the importance of performing root cause analyses

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39841/psn-pdf
    December 18, 2014 - The authors provide additional detailed analyses, including the most frequently affected body parts

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39303/psn-pdf
    February 17, 2010 - patient-misidentification-laboratory-medicine-qualitative-analysis-227-root- cause-analysis Data from root cause analyses

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40736/psn-pdf
    January 04, 2012 - several episodes of incorrect surgical procedures, a medical center conducted individual root cause analyses

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74089/psn-pdf
    July 15, 2002 - Analyses indicate that women and Black patients with chest pain were less likely to be referred for

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44418/psn-pdf
    September 23, 2015 - This work suggests that analyses of adverse events vary in their effectiveness and should be optimized

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45943/psn-pdf
    March 15, 2017 - hours-emergency-department-visit-were-those-deaths-preventable https://psnet.ahrq.gov/issue/rca2-improving-root-cause-analyses-and-actions-prevent-harm

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37797/psn-pdf
    February 03, 2010 - Nursing care requirements also predicted adverse events in limited analyses, which the authors suggest

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41191/psn-pdf
    March 21, 2012 - The authors rate the reviews as moderate and draw a series of recommendations for future such analyses

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44621/psn-pdf
    February 10, 2016 - This study included semistructured interviews with 18 surgical residents, providing qualitative analyses

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45298/psn-pdf
    April 22, 2017 - ://psnet.ahrq.gov/primer/root-cause-analysis https://psnet.ahrq.gov/issue/rca2-improving-root-cause-analyses-and-actions-prevent-harm

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46152/psn-pdf
    May 31, 2017 - Examining root cause analyses of anticoagulation–related adverse events, this study found that the majority

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35017/psn-pdf
    August 24, 2017 - This view of human error has led to the application of root cause analyses and human factors engineering

  15. In Conversation With... James P. Bagian, MD, PE | PSNet

    psnet.ahrq.gov/perspective/conversation-james-p-bagian-md-pe
    February 26, 2025 - influential National Patient Safety Foundation (NPSF) report entitled RCA2: Improving Root Cause Analyses … Wachter : Given your aviation and astronautics background, when you began thinking about root cause analyses … So, the first recommendation is that the analyses need to be risk, not harm, based.

  16. A review of significant events analysed in general practice: implications for the quality and safety of patient care. | PSNet

    psnet.ahrq.gov/issue/review-significant-events-analysed-general-practice-implications-quality-and-safety-patient
    October 29, 2008 - Study A review of significant events analysed in general practice: implications for the quality and safety of patient care. Citation Text: McKay J, Bradley N, Lough M, et al. A review of significant events analysed in general practice: implications for the quality and safety of patient…

  17. Seven hundred and fifty-nine (759) chances to learn: a 3-year pilot project to analyse transfusion-related near-miss events in the Republic of Ireland. | PSNet

    psnet.ahrq.gov/issue/seven-hundred-and-fifty-nine-759-chances-learn-3-year-pilot-project-analyse-transfusion
    September 25, 2008 - Study Seven hundred and fifty-nine (759) chances to learn: a 3-year pilot project to analyse transfusion-related near-miss events in the Republic of Ireland. Citation Text: Lundy D, Laspina S, Kaplan H, et al. Seven hundred and fifty-nine (759) chances to learn: a 3-year pilot project …

  18. Wall of Silence: The Untold Story of the Medical Mistakes That Kill and Injure Millions of Americans. | PSNet

    psnet.ahrq.gov/issue/wall-silence-untold-story-medical-mistakes-kill-and-injure-millions-americans
    January 30, 2003 - Written in a popular style and in an advocate's tone, experts may find the analyses of individual errors

  19. Learning From Mistakes. | PSNet

    psnet.ahrq.gov/issue/learning-mistakes
    March 28, 2018 - The National Health Service (NHS) has a history of sharing analyses of problems in its system.

  20. Patient identification error among prostate needle core biopsy specimens—are we ready for a DNA time-out? | PSNet

    psnet.ahrq.gov/issue/patient-identification-error-among-prostate-needle-core-biopsy-specimens-are-we-ready-dna
    March 12, 2025 - This study summarizes the findings from three root cause analyses to highlight the challenges in preventing
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