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61. Analysis of risk factors for patient safety events occurring in the emergency department. | PSNet
    psnet.ahrq.gov/issue/analysis-risk-factors-patient-safety-events-occurring-emergency-department
    January 26, 2022 - Multivariable analyses showed several potential risk factors for safety events – including length of … May 18, 2022 Root cause analyses of reported adverse events occurring during gastrointestinal

62. Performance variability in perioperative sentinel events: report on a nationwide data set. | PSNet
    psnet.ahrq.gov/issue/performance-variability-perioperative-sentinel-events-report-nationwide-data-set
    November 04, 2020 - The authors suggest that explicitly addressing performance variability in sentinel event analyses can … Related Resources From the Same Author(s) Prioritising recommendations following analyses

63. 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

64. 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

65. 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

66. 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.

67. Root cause analysis of adverse events involving opioid overdoses in the Veterans Health Administration. | PSNet
    psnet.ahrq.gov/issue/root-cause-analysis-adverse-events-involving-opioid-overdoses-veterans-health-administration
    November 17, 2021 - This study conducted root cause analyses of 82 adverse event reports involving opioid use at the Veterans … October 29, 2017 Root cause analyses of reported adverse events occurring during gastrointestinal

68. 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

69. 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

70. 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…

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. 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

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/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

75. 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…

76. 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

77. 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.…

78. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/42564/psn-pdf
    September 11, 2013 - Error rating tool to identify and analyse technical errors and events in laparoscopic surgery. September 11, 2013 Bonrath EM, Zevin B, Dedy NJ, et al. Error rating tool to identify and analyse technical errors and events in laparoscopic surgery. Br J Surg. 2013;100(8):1080-8. doi:10.1002/bjs.9168. https://psnet.ah…

79. 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

80. 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