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psnet.ahrq.gov/node/44497/psn-pdf
September 09, 2015 - VA Health Care: Actions Needed to Assess Decrease in
Root Cause Analyses of Adverse Events. … https://psnet.ahrq.gov/issue/va-health-care-actions-needed-assess-decrease-root-cause-analyses-
adverse-events … medical centers'
application of root cause analysis after adverse events and how findings from these analyses … This report found that the number of root cause analyses performed has
decreased and the NCPS has not … https://psnet.ahrq.gov/issue/va-health-care-actions-needed-assess-decrease-root-cause-analyses-adverse-events
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psnet.ahrq.gov/perspective/conversation-withalbert-wu-md-mph
February 26, 2025 - One is that individual organizations don't seem to follow up on their root cause analyses very well. … Consequently, the results that come out of many root cause analyses are not that useful. … number of root cause analyses. … And also, that those performing root cause analyses have access to clinical experts so that the analyses … We're putting a lot of time and energy and resources into root cause analyses.
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psnet.ahrq.gov/node/42381/psn-pdf
January 01, 2014 - The relationship between safety culture and patient
outcomes: results from pilot meta-analyses. … The relationship between safety culture and patient outcomes: results from pilot meta-
analyses. … /psnet.ahrq.gov/issue/relationship-between-safety-culture-and-patient-outcomes-results-pilot-meta-
analyses … ://psnet.ahrq.gov/issue/relationship-between-safety-culture-and-patient-outcomes-results-pilot-meta-analyses … ://psnet.ahrq.gov/issue/relationship-between-safety-culture-and-patient-outcomes-results-pilot-meta-analyses
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psnet.ahrq.gov/node/35991/psn-pdf
September 12, 2016 - Longitudinal analyses of nurse staffing and patient
outcomes: more about failure to rescue. … Longitudinal Analyses of Nurse Staffing and Patient Outcomes. … https://psnet.ahrq.gov/issue/longitudinal-analyses-nurse-staffing-and-patient-outcomes-more-about-failure … https://psnet.ahrq.gov/issue/longitudinal-analyses-nurse-staffing-and-patient-outcomes-more-about-failure-rescue … https://psnet.ahrq.gov/issue/longitudinal-analyses-nurse-staffing-and-patient-outcomes-more-about-failure-rescue
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psnet.ahrq.gov/node/39516/psn-pdf
June 27, 2011 - Risk and pharmacoeconomic analyses of the injectable
medication process in the paediatric and neonatal … Risk and pharmacoeconomic analyses of the injectable
medication process in the paediatric and neonatal … https://psnet.ahrq.gov/issue/risk-and-pharmacoeconomic-analyses-injectable-medication-process-
paediatric-and-neonatal … https://psnet.ahrq.gov/issue/risk-and-pharmacoeconomic-analyses-injectable-medication-process-paediatric-and-neonatal … https://psnet.ahrq.gov/issue/risk-and-pharmacoeconomic-analyses-injectable-medication-process-paediatric-and-neonatal
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psnet.ahrq.gov/node/36520/psn-pdf
June 14, 2011 - Experiences of health professionals who conducted root
cause analyses after undergoing a safety improvement … Experiences of health professionals who conducted root
cause analyses after undergoing a safety improvement … https://psnet.ahrq.gov/issue/experiences-health-professionals-who-conducted-root-cause-analyses-after … https://psnet.ahrq.gov/issue/experiences-health-professionals-who-conducted-root-cause-analyses-after-undergoing-safety … https://psnet.ahrq.gov/issue/experiences-health-professionals-who-conducted-root-cause-analyses-after-undergoing-safety
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psnet.ahrq.gov/node/45693/psn-pdf
February 22, 2017 - Meta-analyses of the effects of standardized handoff
protocols on patient, provider, and organizational … Meta-Analyses of the Effects of Standardized Handoff Protocols
on Patient, Provider, and Organizational … https://psnet.ahrq.gov/issue/meta-analyses-effects-standardized-handoff-protocols-patient-provider-and … https://psnet.ahrq.gov/issue/meta-analyses-effects-standardized-handoff-protocols-patient-provider-and-organizational … https://psnet.ahrq.gov/issue/meta-analyses-effects-standardized-handoff-protocols-patient-provider-and-organizational
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psnet.ahrq.gov/node/41482/psn-pdf
June 27, 2012 - Bayesian cohort and cross-sectional analyses of the
PINCER trial: a pharmacist-led intervention to reduce … Bayesian cohort and cross-sectional analyses of the PINCER trial:
a pharmacist-led intervention to reduce … https://psnet.ahrq.gov/issue/bayesian-cohort-and-cross-sectional-analyses-pincer-trial-pharmacist-led … https://psnet.ahrq.gov/issue/bayesian-cohort-and-cross-sectional-analyses-pincer-trial-pharmacist-led-intervention-reduce … https://psnet.ahrq.gov/issue/bayesian-cohort-and-cross-sectional-analyses-pincer-trial-pharmacist-led-intervention-reduce
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psnet.ahrq.gov/node/45108/psn-pdf
October 11, 2017 - IT-CARES: an interactive tool for case-crossover analyses
of electronic medical records for patient … IT-CARES: an interactive tool for case-crossover analyses of electronic
medical records for patient … https://psnet.ahrq.gov/issue/it-cares-interactive-tool-case-crossover-analyses-electronic-medical-records … https://psnet.ahrq.gov/issue/it-cares-interactive-tool-case-crossover-analyses-electronic-medical-records-patient-safety … https://psnet.ahrq.gov/issue/it-cares-interactive-tool-case-crossover-analyses-electronic-medical-records-patient-safety
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psnet.ahrq.gov/issue/longitudinal-analyses-nurse-staffing-and-patient-outcomes-more-about-failure-rescue
February 24, 2021 - Study
Longitudinal analyses of nurse staffing and patient outcomes: more about failure … Longitudinal Analyses of Nurse Staffing and Patient Outcomes. … Longitudinal Analyses of Nurse Staffing and Patient Outcomes.
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psnet.ahrq.gov/issue/does-standardisation-improve-post-operative-anaesthesia-handoffs-meta-analyses-provider
June 29, 2022 - Meta-analyses on provider, patient, organisational, and handoff outcomes. … Meta-analyses on provider, patient, organisational, and handoff outcomes. … Meta-analyses on provider, patient, organisational, and handoff outcomes.
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psnet.ahrq.gov/issue/trends-diagnostic-adverse-events-hospital-deaths-longitudinal-analyses-four-retrospective
May 18, 2022 - Study
Trends of diagnostic adverse events in hospital deaths: longitudinal analyses … Trends of diagnostic adverse events in hospital deaths: longitudinal analyses of four retrospective record … Trends of diagnostic adverse events in hospital deaths: longitudinal analyses of four retrospective record
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psnet.ahrq.gov/node/39034/psn-pdf
November 25, 2009 - AHRQ's Hospital Survey on Patient Safety Culture:
psychometric analyses. … AHRQ's hospital survey on patient safety culture: psychometric
analyses. … https://psnet.ahrq.gov/issue/ahrqs-hospital-survey-patient-safety-culture-psychometric-analyses
The … https://psnet.ahrq.gov/issue/ahrqs-hospital-survey-patient-safety-culture-psychometric-analyses
https
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psnet.ahrq.gov/node/39558/psn-pdf
May 26, 2010 - ReCASTing the RCA: an improved model for performing
root cause analyses. … ReCASTing the RCA: An Improved Model for Performing Root
Cause Analyses. … https://psnet.ahrq.gov/issue/recasting-rca-improved-model-performing-root-cause-analyses
This article … https://psnet.ahrq.gov/issue/recasting-rca-improved-model-performing-root-cause-analyses
https://psnet.ahrq.gov
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psnet.ahrq.gov/node/45255/psn-pdf
January 23, 2017 - Provider risk factors for medication administration error
alerts: analyses of a large-scale closed-loop … Provider risk factors for medication administration error alerts: analyses
of a large-scale closed-loop … https://psnet.ahrq.gov/issue/provider-risk-factors-medication-administration-error-alerts-analyses-large … https://psnet.ahrq.gov/issue/provider-risk-factors-medication-administration-error-alerts-analyses-large-scale-closed-loop … https://psnet.ahrq.gov/issue/provider-risk-factors-medication-administration-error-alerts-analyses-large-scale-closed-loop
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psnet.ahrq.gov/node/44685/psn-pdf
November 18, 2015 - Root cause analyses of suicides of mental health clients. … Root Cause Analyses of Suicides of Mental Health Clients: Identifying
Systematic Processes and Service-Level … https://psnet.ahrq.gov/issue/root-cause-analyses-suicides-mental-health-clients
This study used root … https://psnet.ahrq.gov/issue/root-cause-analyses-suicides-mental-health-clients
https://psnet.ahrq.gov
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psnet.ahrq.gov/issue/relationship-between-safety-culture-and-patient-outcomes-results-pilot-meta-analyses
January 08, 2020 - The relationship between safety culture and patient outcomes: results from pilot meta-analyses … The relationship between safety culture and patient outcomes: results from pilot meta-analyses. … The relationship between safety culture and patient outcomes: results from pilot meta-analyses.
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psnet.ahrq.gov/training-catalog/ihi-redesigning-event-review-root-cause-analyses-and-actions-rca2
IHI Redesigning Event Review with Root Cause Analyses and Actions (RCA2)
Save
Save
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psnet.ahrq.gov/issue/exploratory-analyses-failure-rescue-measure-evaluation-through-medical-record-review
December 15, 2008 - Study
Exploratory analyses of the "failure to rescue" measure: evaluation through … Exploratory analyses of the "failure to rescue" measure: evaluation through medical record review. … Exploratory analyses of the "failure to rescue" measure: evaluation through medical record review.
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psnet.ahrq.gov/node/44246/psn-pdf
November 15, 2016 - RCA2: Improving Root Cause Analyses and Actions to
Prevent Harm. … https://psnet.ahrq.gov/issue/rca2-improving-root-cause-analyses-and-actions-prevent-harm
The National … Patient Safety Foundation issued these guidelines for improving root cause analyses (RCAs)
in health … https://psnet.ahrq.gov/issue/rca2-improving-root-cause-analyses-and-actions-prevent-harm
https://psnet.ahrq.gov