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

    psnet.ahrq.gov/node/39197/psn-pdf
    January 06, 2010 - In this study, investigators performed root cause analyses on more than 100 cases of sentinel events

  2. Learning Not Blaming. | PSNet

    psnet.ahrq.gov/issue/learning-not-blaming
    March 28, 2018 - The National Health Service (NHS) has a history of sharing analyses of problems in its system.

  3. The Field Guide to Human Error Investigations, Third Edition. | PSNet

    psnet.ahrq.gov/issue/field-guide-human-error-investigations-third-edition
    April 13, 2018 - This view of human error has led to the application of root cause analyses and human factors engineering

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46155/psn-pdf
    December 21, 2017 - In adjusted analyses, this effort led to a significant decrease in catheter-associated urinary tract

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40636/psn-pdf
    November 21, 2011 - Root cause analyses of errors revealed that lack of standardization and human factors issues were major

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42816/psn-pdf
    October 31, 2014 - In the uncontrolled, before-and-after analyses, medical errors and preventable adverse events decreased

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42882/psn-pdf
    November 23, 2016 - adverse events, they are rarely asked to participate in medical error investigations, such as root cause analyses

  8. Identifying causes of adverse events detected by an automated trigger tool through in-depth analysis. | PSNet

    psnet.ahrq.gov/issue/identifying-causes-adverse-events-detected-automated-trigger-tool-through-depth-analysis
    October 05, 2011 - possible medication errors using trigger tools , and a multidisciplinary team conducted real-time analyses

  9. Recognizing and managing errors of cognitive underspecification. | PSNet

    psnet.ahrq.gov/issue/recognizing-and-managing-errors-cognitive-underspecification
    November 14, 2018 - This commentary uses case analyses to illustrate how such incomplete discussions often contribute to

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46545/psn-pdf
    March 27, 2018 - ://psnet.ahrq.gov/issue/relationship-between-safety-culture-and-patient-outcomes-results-pilot-meta-analyses

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45207/psn-pdf
    August 17, 2016 - unit-based-incident-reporting-and-root-cause-analysis-variation-three-hospital- unit-types Incident reporting systems and root cause analyses

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35572/psn-pdf
    February 03, 2011 - administration and safety procedures, error reporting processes, prevention policies, and root cause analyses

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43301/psn-pdf
    May 01, 2015 - have shown that walkrounds can improve safety culture, but both randomized trials and qualitative analyses

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43917/psn-pdf
    November 03, 2015 - Lucian Leape notes that analyses of these surgical complications can serve as "treasures" for providing

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37484/psn-pdf
    April 01, 2010 - provide detailed comparisons of their findings to those of a previous study that conducted similar analyses

  16. Preventing medication errors in community pharmacy: root-cause analysis of transcription errors. | PSNet

    psnet.ahrq.gov/issue/preventing-medication-errors-community-pharmacy-root-cause-analysis-transcription-errors
    March 24, 2011 - This study reports the results of root-cause analyses of medication errors reported by Danish pharmacies

  17. Root cause analysis of ambulatory adverse drug events that present to the emergency department. | PSNet

    psnet.ahrq.gov/issue/root-cause-analysis-ambulatory-adverse-drug-events-present-emergency-department
    April 25, 2016 - This study used root cause analyses —which incorporated patient perspectives —of ED visits for ADEs

  18. Adverse Events in Hospitals: State Reporting Systems. | PSNet

    psnet.ahrq.gov/issue/adverse-events-hospitals-state-reporting-systems
    January 14, 2009 - Care Act of 2006 mandated that the Office of Inspector General (OIG) report to Congress a series of analyses

  19. Adverse Events in Hospitals: Medicare's Responses to Alleged Serious Events. | PSNet

    psnet.ahrq.gov/issue/adverse-events-hospitals-medicares-responses-alleged-serious-events
    February 18, 2009 - The Office of the Inspector General (OIG) has conducted a series of analyses of adverse event incidence

  20. Discrepant advanced directives and code status orders: a preventable medical error. | PSNet

    psnet.ahrq.gov/issue/discrepant-advanced-directives-and-code-status-orders-preventable-medical-error
    October 31, 2018 - Root cause analyses for these cases found that haste, inadequate communication, EMR discrepancies, knowledge
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