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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73420/psn-pdf
    June 23, 2021 - This study conducted root cause analyses of 82 adverse event reports involving opioid use at the Veterans
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851356/psn-pdf
    July 12, 2023 - https://psnet.ahrq.gov/issue/does-standardisation-improve-post-operative-anaesthesia-handoffs-meta-analyses-provider
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867596/psn-pdf
    January 22, 2025 - implementing-root-cause-analysis-and-action-integrating-human-factors-create-strong https://psnet.ahrq.gov/issue/rca2-improving-root-cause-analyses-and-actions-prevent-harm
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836966/psn-pdf
    April 20, 2022 - The authors suggest that explicitly addressing performance variability in sentinel event analyses can
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72814/psn-pdf
    March 10, 2021 - implementing-human-factors-approach-rca2-tools-processes-and-strategies https://psnet.ahrq.gov/issue/rca2-improving-root-cause-analyses-and-actions-prevent-harm
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73610/psn-pdf
    January 01, 2022 - Analyses suggest that atypical presentation was often characterized by functional decline or altered
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50432/psn-pdf
    September 04, 2019 - inpatient-suicide-mental-health-units-veterans-affairs-va-hospitals-avoiding-environmental https://psnet.ahrq.gov/issue/root-cause-analyses-suicides-mental-health-clients
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73634/psn-pdf
    August 25, 2021 - Analyses show that the e-trigger identified missed diagnoses of stroke with a modest positive predictive
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838077/psn-pdf
    September 14, 2022 - Analyses showed that patients were designated as “alternate level of care” (ALC) for an average of 56
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837794/psn-pdf
    August 10, 2022 - Analyses identified limited improvement in quality and patient safety indicators.
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74200/psn-pdf
    January 01, 2022 - Subgroup analyses indicate that this relationship is driven by worse outcomes among female patients
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/862608/psn-pdf
    February 14, 2024 - Thematic analyses identified three priority areas to improve patient experience and safety during preterm
  13. psnet.ahrq.gov/issue/studying-organisational-cultures-and-their-effects-safety
    April 20, 2014 - The author shares examples of cultural analyses and provides suggestions for effective research on safety
  14. psnet.ahrq.gov/issue/investigation-and-analysis-critical-incidents-and-adverse-events-healthcare
    March 05, 2014 - Study Classic The investigation and analysis of critical incidents and adverse events in healthcare. Citation Text: Woloshynowych M, Rogers S, Taylor-Adams S, et al. The investigation and analysis of critical incidents and adverse events in healthcare. Health …
  15. psnet.ahrq.gov/issue/conducting-safety-research-safely-policy-based-approach-conducting-research-peer-review
    June 15, 2022 - for the use of peer review protected information (such as  voluntary event reports  and  root causes analyses
  16. psnet.ahrq.gov/issue/factors-associated-potentially-missed-diagnosis-appendicitis-emergency-department
    December 16, 2020 - Stratified analyses based on undifferentiated symptoms found that women and patients with comorbidities
  17. psnet.ahrq.gov/issue/value-assessment-deprescribing-interventions-suggestions-improvement
    August 04, 2021 - This article outlines several recommendations for improved cost-effectiveness analyses of deprescribing
  18. psnet.ahrq.gov/issue/diagnostic-reliability-teledermatology-systematic-review-and-meta-analysis
    September 23, 2020 - The overall average diagnostic agreement was 68.9%, but subgroup analyses identified significantly higher
  19. psnet.ahrq.gov/issue/evidence-based-toolkit-development-effective-and-sustainable-root-cause-analysis-system
    June 01, 2019 - The authors reviewed 334 root cause analyses (RCA) using systems science principles to create a toolkit
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60643/psn-pdf
    July 01, 2020 - Analyses also found an association between PPE discomfort and situational awareness, but this association

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