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61. Association between handover of anesthesiology care and 1-year mortality among adults undergoing cardiac surgery. | PSNet
    psnet.ahrq.gov/issue/association-between-handover-anesthesiology-care-and-1-year-mortality-among-adults-undergoing
    June 08, 2022 - Analyses revealed that anesthesia handovers were associated with poorer outcomes (i.e., higher 30-day … Meta-analyses on provider, patient, organisational, and handoff outcomes.

62. Association of state-level opioid-reduction policies with pediatric opioid poisoning. | PSNet
    psnet.ahrq.gov/issue/association-state-level-opioid-reduction-policies-pediatric-opioid-poisoning
    September 09, 2020 - Analyses of prescribing guidelines did not show a change in the rate of opioid poisoning. … following two policies in North Carolina, 2012-2018 - controlled and single-series interrupted time series analyses

63. Use of a prospective risk analysis method to improve the safety of the cancer chemotherapy process. | PSNet
    psnet.ahrq.gov/issue/use-prospective-risk-analysis-method-improve-safety-cancer-chemotherapy-process
    May 29, 2019 - Investigators performed their analyses after reengineering of the medication administration process and … December 17, 2014 Risk and pharmacoeconomic analyses of the injectable medication process

64. Patient complaints in healthcare systems: a systematic review and coding taxonomy. | PSNet
    psnet.ahrq.gov/issue/patient-complaints-healthcare-systems-systematic-review-and-coding-taxonomy
    November 29, 2023 - sought to create a common taxonomy for patient complaints in order to standardize future research and analyses … This taxonomy may enable comparisons between health care institutions and more sophisticated aggregate analyses

65. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/41287/psn-pdf
    May 17, 2012 - that estimated the cost of adverse events, the cost of patient safety practices, and cost–benefit analyses … identified, the majority only characterized the cost of adverse events, and few formal cost–benefit analyses

66. Learning from incident reporting? Analysis of incidents resulting in patient injuries in a web-based system in Swedish health care. | PSNet
    psnet.ahrq.gov/issue/learning-incident-reporting-analysis-incidents-resulting-patient-injuries-web-based-system
    August 04, 2021 - Incident reporting systems and root cause analyses are the primary mechanisms by which adverse events … June 15, 2022 Root cause analyses of reported adverse events occurring during gastrointestinal

67. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/43988/psn-pdf
    February 22, 2018 - actions for improvement with the Healthcare Failure Mode Effect Analysis method: evaluation of 117 analyses … Actions for Improvement With the Healthcare Failure Mode Effect Analysis Method: Evaluation of 117 Analyses

68. The impact of surgical count technology on retained surgical items rates in the Veterans Health Administration. | PSNet
    psnet.ahrq.gov/issue/impact-surgical-count-technology-retained-surgical-items-rates-veterans-health-administration
    January 17, 2019 - programs with (n=46) and without (n=91) surgical count technology  and analyzed the resulting root cause analyses … August 21, 2019 Root cause analyses of reported adverse events occurring during gastrointestinal

69. Educational levels of hospital nurses and surgical patient mortality. | PSNet
    psnet.ahrq.gov/issue/educational-levels-hospital-nurses-and-surgical-patient-mortality
    February 09, 2011 - examines the relationship between nursing educational levels and patient outcomes using cross-sectional analyses … September 26, 2018 Longitudinal analyses of nurse staffing and patient outcomes: more

70. Actions and implementation strategies to reduce suicidal events in the Veterans Health Administration. | PSNet
    psnet.ahrq.gov/issue/actions-and-implementation-strategies-reduce-suicidal-events-veterans-health-administration
    January 05, 2017 - The investigators examined root cause analyses regarding suicide and parasuicidal behaviors. … August 21, 2019 Root cause analyses of reported adverse events occurring during gastrointestinal

71. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/44626/psn-pdf
    November 04, 2015 - //psnet.ahrq.gov/issue/swarming-improve-patient-care-novel-approach-root-cause-analysis Root cause analyses … ://psnet.ahrq.gov/primer/root-cause-analysis https://psnet.ahrq.gov/issue/rca2-improving-root-cause-analyses-and-actions-prevent-harm

72. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/43263/psn-pdf
    July 16, 2014 - sought to create a common taxonomy for patient complaints in order to standardize future research and analyses … taxonomy may enable comparisons between health care institutions and more sophisticated aggregate analyses

73. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/43207/psn-pdf
    April 25, 2016 - study analyzed information from the Veterans Health Administration national database of root cause analyses … Although virtually all root cause analyses led to implementation of action plans, only 40% were deemed

74. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/855098/psn-pdf
    November 08, 2023 - Innovative approaches to analysing aged care falls incident data: International Classification for Patient Safety and correspondence analysis. November 8, 2023 Seaman K, Meulenbroeks I, Nguyen A, et al. Innovative approaches to analysing aged care falls incident data: international classification for patient safet…

75. Turning the medical gaze in upon itself: root cause analysis and the investigation of clinical error. | PSNet
    psnet.ahrq.gov/issue/turning-medical-gaze-upon-itself-root-cause-analysis-and-investigation-clinical-error
    June 14, 2011 - June 14, 2011 Experiences of health professionals who conducted root cause analyses after … September 19, 2016 Root cause analyses of suicides of mental health clients. … June 14, 2011 Experiences of health professionals who conducted root cause analyses after

76. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/867652/psn-pdf
    February 26, 2025 - https://psnet.ahrq.gov/primer/culture-safety https://psnet.ahrq.gov/issue/rca2-improving-root-cause-analyses-and-actions-prevent-harm … annual-perspective-psychological-safety-healthcare-staff https://psnet.ahrq.gov/issue/rca2-improving-root-cause-analyses-and-actions-prevent-harm … This adaptability allows organizations to start small or tackle complex analyses all at once, depending … RCA2: Improving root cause analyses and actions to prevent harm. … patientsafety/adverseevents/toolkit/index.html https://www.ihi.org/resources/tools/rca2-improving-root-cause-analyses-and-actions-prevent-harm

77. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/33825/psn-pdf
    January 01, 2017 - the National Patient Safety Foundation (NPSF) released a report entitled RCA2: Improving Root Cause Analyses … RCA2: Improving Root Cause Analyses and Actions to Prevent Harm: 9 Recommendations From NPSF 1. … Source: RCA2: Improving Root Cause Analyses and Actions to Prevent Harm. … https://psnet.ahrq.gov/issue/rca2-improving-root-cause-analyses-and-actions-prevent-harm https://psnet.ahrq.gov … /issue/rca2-improving-root-cause-analyses-and-actions-prevent-harm https://psnet.ahrq.gov/issue/problem-root-cause-analysis

78. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/38878/psn-pdf
    September 26, 2016 - Reducing the disruptive effects of interruption: a cognitive framework for analysing the costs and benefits of intervention strategies. September 26, 2016 Boehm-Davis DA, Remington R. Reducing the disruptive effects of interruption: a cognitive framework for analysing the costs and benefits of intervention strateg…

79. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/39011/psn-pdf
    October 14, 2009 - A review of significant events analysed in general practice: implications for the quality and safety of patient care. October 14, 2009 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 care. BMC Fam Pract. 2009;10:61.…

80. Medication safety in emergency medical services: approaching an evidence-based method of verification to reduce errors. | PSNet
    psnet.ahrq.gov/issue/medication-safety-emergency-medical-services-approaching-evidence-based-method-verification
    September 28, 2022 - July 12, 2023 Meta-analyses of the effects of standardized handoff protocols on patient … Meta-analyses on provider, patient, organisational, and handoff outcomes.