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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. Provider risk factors for medication administration error alerts: analyses of a large-scale closed-loop medication administration system using RFID and barcode. | PSNet
    psnet.ahrq.gov/issue/provider-risk-factors-medication-administration-error-alerts-analyses-large-scale-closed-loop
    September 01, 2016 - Study Provider risk factors for medication administration error alerts: analyses … 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

63. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/45953/psn-pdf
    July 22, 2020 - root-cause-analysis-swatting-mosquitoes-versus-draining-swamp 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

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. 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

66. 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

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/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

72. 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

73. 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

74. 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

75. 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

76. 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

77. Root cause analysis reports help identify common factors in delayed diagnosis and treatment of outpatients. | PSNet
    psnet.ahrq.gov/issue/root-cause-analysis-reports-help-identify-common-factors-delayed-diagnosis-and-treatment
    October 24, 2018 - By analyzing 111 root cause analyses of diagnostic error cases in the outpatient setting, the authors … April 12, 2019 Root cause analyses of reported adverse events occurring during gastrointestinal

78. How reliable is your hospital? A qualitative framework for analysing reliability levels. | PSNet
    psnet.ahrq.gov/issue/how-reliable-your-hospital-qualitative-framework-analysing-reliability-levels
    October 19, 2022 - Commentary How reliable is your hospital? A qualitative framework for analysing reliability levels. Citation Text: Ikkersheim DE, Berg M. How reliable is your hospital? A qualitative framework for analysing reliability levels. BMJ Qual Saf. 2011;20(9):785-790. Copy Citation Format…

79. Analysing potential harm in Australian general practice: an incident-monitoring study. | PSNet
    psnet.ahrq.gov/issue/analysing-potential-harm-australian-general-practice-incident-monitoring-study
    July 29, 2020 - Study Classic Analysing potential harm in Australian general practice: an incident-monitoring study. Citation Text: Bhasale AL, Miller GC, Reid SE, et al. Analysing potential harm in Australian general practice: an incident-monitoring study. Med J Aust. 1998;1…

80. Handoff mnemonics used in perioperative handoff intervention studies: a systematic review. | PSNet
    psnet.ahrq.gov/issue/handoff-mnemonics-used-perioperative-handoff-intervention-studies-systematic-review
    November 16, 2022 - Meta-analyses on provider, patient, organisational, and handoff outcomes. … October 7, 2013 Meta-analyses of the effects of standardized handoff protocols on patient