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

    psnet.ahrq.gov/node/45859/psn-pdf
    August 03, 2017 - patient-safety-orthopedic-surgery-prioritizing-key-areas-iatrogenic-harm-through-analysis https://psnet.ahrq.gov/issue/rca2-improving-root-cause-analyses-and-actions-prevent-harm

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47508/psn-pdf
    October 24, 2018 - root-cause-analysis-reported-patient-falls-ors-veterans-health-administration https://psnet.ahrq.gov/issue/rca2-improving-root-cause-analyses-and-actions-prevent-harm

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35418/psn-pdf
    June 14, 2011 - Subsequent root cause analyses identified system factors that contributed to the errors, and the authors

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37310/psn-pdf
    January 05, 2012 - patient-identification-error-among-prostate-needle-core-biopsy-specimens-are- we-ready-dna This study summarizes the findings from three root cause analyses

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43281/psn-pdf
    May 28, 2015 - effectiveness-and-efficiency-root-cause-analysis-medicine https://psnet.ahrq.gov/issue/recasting-rca-improved-model-performing-root-cause-analyses

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43154/psn-pdf
    August 22, 2016 - This study used root cause analyses—which incorporated patient perspectives—of ED visits for ADEs to

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34803/psn-pdf
    January 05, 2017 - examples of events analyzed, and an informative table sharing systematic changes resulting from the analyses

  8. Patient misidentification in laboratory medicine: a qualitative analysis of 227 root cause analysis reports in the Veterans Health Administration. | PSNet

    psnet.ahrq.gov/issue/patient-misidentification-laboratory-medicine-qualitative-analysis-227-root-cause-analysis
    August 28, 2024 - Data from root cause analyses were used to identify causal factors for patient misidentification errors

  9. 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

  10. Man-Made Disasters. 2nd ed. | PSNet

    psnet.ahrq.gov/issue/man-made-disasters-2nd-ed
    January 01, 2012 - For those interested in potential lessons drawn from analyses of major accidents in other industries,

  11. Unlocking Solutions in Imaging: Working Together to Learn from Failings in the NHS. | PSNet

    psnet.ahrq.gov/issue/unlocking-solutions-imaging-working-together-learn-failings-nhs
    October 07, 2020 - Recommendations to improve imaging in the NHS include use of previous analyses to enhance learning

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44483/psn-pdf
    September 09, 2015 - psnet.ahrq.gov/issue/learning-not-blaming The National Health Service (NHS) has a history of sharing analyses

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45510/psn-pdf
    October 19, 2016 - diagramming-patients-views-root-causes-adverse-drug-events-ambulatory-care-online-tool https://psnet.ahrq.gov/issue/rca2-improving-root-cause-analyses-and-actions-prevent-harm

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35497/psn-pdf
    June 30, 2011 - Investigators performed their analyses after reengineering of the medication administration process

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44818/psn-pdf
    February 24, 2018 - This systematic review examined economic analyses of interventions to prevent hospital-acquired infections

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35328/psn-pdf
    May 19, 2015 - conclude that HFMEA may allow systems to uncover latent errors  beyond those discovered with root cause analyses

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46583/psn-pdf
    December 18, 2017 - Although this study design cannot control for secular trends, few crew resource management analyses

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45967/psn-pdf
    July 05, 2017 - ://psnet.ahrq.gov/primer/root-cause-analysis https://psnet.ahrq.gov/issue/rca2-improving-root-cause-analyses-and-actions-prevent-harm

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37784/psn-pdf
    May 27, 2011 - quantitative analysis, following a failure mode and effect analysis (FMEA), and concluded that such analyses

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38334/psn-pdf
    January 14, 2009 - Care Act of 2006 mandated that the Office of Inspector General (OIG) report to Congress a series of analyses
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