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A qualitative content analysis of retained surgical items: learning from root cause analysis investigations. | PSNet

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December 06, 2023 - Study A qualitative content analysis of retained surgical items: learning from root … cause analysis investigations. … A qualitative content analysis of retained surgical items: learning from root cause analysis investigations … A qualitative content analysis of retained surgical items: learning from root cause analysis investigations … A content analysis of accreditation reports.

Root Cause Analysis | PSNet

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March 30, 2022 - Root Cause Analysis Citation Text: Root Cause Analysis. PSNet [internet]. … Background Root cause analysis (RCA) is a structured method used to analyze serious adverse events. … Accordingly, some have suggested replacing the term "root cause analysis" with "systems analysis." … Effectiveness of Root Cause Analysis Root cause analysis is one of the most widely used approaches to … June 5, 2024 What are the experiences of team members involved in root cause analysis?

Assisting beginners in root cause analysis operations: analysis and recommendations regarding the spread of COVID-19 in nursing facilities for the elderly. | PSNet

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June 08, 2022 - Commentary Assisting beginners in root cause analysis operations: analysis and recommendations … Assisting beginners in root cause analysis operations: analysis and recommendations regarding the spread … Assisting beginners in root cause analysis operations: analysis and recommendations regarding the spread … program using root cause analysis and common cause analysis. … of patient safety and root cause analysis reports in the Veterans Health Administration.

Review of alternatives to root cause analysis: developing a robust system for incident report analysis. | PSNet

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November 14, 2018 - Review Review of alternatives to root cause analysis: developing a robust system … for incident report analysis. … Review of alternatives to root cause analysis: developing a robust system for incident report analysis … with root cause analysis, such as time commitment and lack of follow up. … Review of alternatives to root cause analysis: developing a robust system for incident report analysis

Analysis of readmissions in a mobile integrated health transitional care program using root cause analysis and common cause analysis. | PSNet

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June 08, 2022 - using root cause analysis and common cause analysis. … Analysis of readmissions in a mobile integrated health transitional care program using root cause analysis … and common cause analysis. … Analysis of readmissions in a mobile integrated health transitional care program using root cause analysis … and common cause analysis.

Common cause analysis. | PSNet

psnet.ahrq.gov/issue/common-cause-analysis

June 27, 2018 - Newspaper/Magazine Article Common cause analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … May 7, 2018 ISMP medication error report analysis.

Root cause analysis. | PSNet

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June 15, 2016 - Commentary Root cause analysis. Citation Text: Stecker MS. … Root cause analysis. J Vasc Interv Radiol. 2007;18(1 Pt 1):5-8. … The author provides an introduction to root cause analysis and its application to study and prevent … Root cause analysis. J Vasc Interv Radiol. 2007;18(1 Pt 1):5-8. … 2022 Clarifying radiology's role in safety events: a 5-year retrospective common cause analysis

Root Cause Analysis in Health Care: A Joint Commission Guide to Analysis and Corrective Action of Sentinel and Adverse Events. | PSNet

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November 27, 2018 - Book/Report Root Cause Analysis in Health Care: A Joint Commission Guide to Analysis … Citation Text: Root Cause Analysis in Health Care: A Joint Commission Guide to Analysis and Corrective … Root cause analysis has been widely adopted as a strategy to investigate events, despite questions … This revised publication provides information about updated approaches to root cause analysis with … It highlights the use of failure mode and effects analysis as a complementary sentinel event examination

Root cause analysis using the prevention and recovery information system for monitoring and analysis method in healthcare facilities: a systematic literature review. | PSNet

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May 18, 2022 - Review Root cause analysis using the prevention and recovery information system for … monitoring and analysis method in healthcare facilities: a systematic literature review. … Root cause analysis using the prevention and recovery information system for monitoring and analysis … Root cause analysis using the prevention and recovery information system for monitoring and analysis … of patient safety and root cause analysis reports in the Veterans Health Administration.

An analysis of adverse events in the rehabilitation department: using the Veterans Affairs root cause analysis system. | PSNet

psnet.ahrq.gov/issue/analysis-adverse-events-rehabilitation-department-using-veterans-affairs-root-cause-analysis

June 21, 2017 - Affairs root cause analysis system. … Analysis System. … This analysis of the Veterans Health Administration root cause analysis database identified adverse … Analysis System. … for incident report analysis.

Errors and analysis of errors. | PSNet

psnet.ahrq.gov/issue/errors-and-analysis-errors

August 28, 2019 - Commentary Errors and analysis of errors. … Errors and analysis of errors. … , failure mode and effects analysis (FMEA), and human factors. … Errors and analysis of errors. … July 14, 2010 Root cause analysis of cases involving diagnosis.

Random safety auditing, root cause analysis, failure mode and effects analysis. | PSNet

psnet.ahrq.gov/issue/random-safety-auditing-root-cause-analysis-failure-mode-and-effects-analysis

April 11, 2011 - Commentary Random safety auditing, root cause analysis, failure mode and effects … analysis. … Random Safety Auditing, Root Cause Analysis, Failure Mode and Effects Analysis. … This essay introduces three primary analysis techniques from industry that demonstrate effectiveness … Random Safety Auditing, Root Cause Analysis, Failure Mode and Effects Analysis.

The problem with root cause analysis. | PSNet

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August 28, 2024 - Commentary The problem with root cause analysis. … The problem with root cause analysis. … Root cause analysis (RCA) is a strategy to investigate incidents that has gained acceptance in health … The problem with root cause analysis. … A qualitative study combining human factors/ergonomics and social science analysis.

Health Care Failure Mode and Effect Analysis: a useful proactive risk analysis in a pediatric oncology ward. | PSNet

psnet.ahrq.gov/issue/health-care-failure-mode-and-effect-analysis-useful-proactive-risk-analysis-pediatric

June 13, 2011 - Study Health Care Failure Mode and Effect Analysis: a useful proactive risk analysis … Health Care Failure Mode and Effect Analysis: a useful proactive risk analysis in a pediatric oncology … The authors applied the VA's Health Care Failure Mode and Effect Analysis (HFMEA) process to vincristine … Health Care Failure Mode and Effect Analysis: a useful proactive risk analysis in a pediatric oncology … June 13, 2011 Prospective risk analysis of health care processes: a systematic evaluation

The Evolution of Root Cause Analysis | PSNet

psnet.ahrq.gov/perspective/evolution-root-cause-analysis

February 26, 2025 - The Evolution of Root Cause Analysis. PSNet [internet]. … The Evolution of Root Cause Analysis. PSNet [internet]. … Using aggregate root cause analysis to improve patient safety. … Jessica Behrhorst: RCA 2 is not just root cause analysis but root cause analysis and action. … The Evolution of Root Cause Analysis. PSNet [internet].

The hard work of failure analysis. | PSNet

psnet.ahrq.gov/issue/hard-work-failure-analysis

September 06, 2023 - Newspaper/Magazine Article The hard work of failure analysis. … Citation Text: The hard work of failure analysis. Edmondson A, Cannon MD. Working Knowledge. … reviews examples from health care and other sectors where learning is achieved through thoughtful failure analysis … Cite Citation Citation Text: The hard work of failure analysis … Care Providers Health Care Executives and Administrators Non-Health Care Professionals Error Analysis

Root Cause Analysis Playbook. | PSNet

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July 05, 2017 - Book/Report Root Cause Analysis Playbook. … Citation Text: Root Cause Analysis Playbook. … June 4, 2024 Root Cause Analysis in Health Care: A Joint Commission Guide to Analysis … July 22, 2020 Medical Device Use Error: Root Cause Analysis. … May 21, 2019 Improving reliability with root cause analysis.

Canadian Incident Analysis Framework. | PSNet

psnet.ahrq.gov/issue/canadian-incident-analysis-framework

December 04, 2016 - Book/Report Canadian Incident Analysis Framework. … Citation Text: Canadian Incident Analysis Framework. Incident Analysis Collaborating Parties. … Performing incident analysis can help organizations understand why adverse events occur and how to … Incident Analysis Collaborating Parties. Edmonton, AB: Canadian Patient Safety Institute; 2012. … Analysis of incident reports from a patient safety organization.

Rethinking Root Cause Analysis | PSNet

psnet.ahrq.gov/perspective/rethinking-root-cause-analysis

August 21, 2016 - Rethinking Root Cause Analysis. PSNet [internet]. … Rethinking Root Cause Analysis. PSNet [internet]. … Problems With Root Cause Analysis in Health Care 1. … The problem with root cause analysis. BMJ Qual Saf. 2017;26:417-422. … Rethinking Root Cause Analysis. PSNet [internet].

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 - Study Patient misidentification in laboratory medicine: a qualitative analysis of … 227 root cause analysis reports in the Veterans Health Administration. … Patient misidentification in laboratory medicine: a qualitative analysis of 227 root cause analysis reports … Patient misidentification in laboratory medicine: a qualitative analysis of 227 root cause analysis reports … April 30, 2014 Root cause analysis reports help identify common factors in delayed diagnosis

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