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141. Human error and the problem of causality in analysis of accidents. | PSNet
     psnet.ahrq.gov/issue/human-error-and-problem-causality-analysis-accidents
     August 25, 2021 - Commentary Classic Human error and the problem of causality in analysis … Human error and the problem of causality in analysis of accidents. … Discussion includes the causal analysis of accidents, human error and behavior, human and system adaptation … Human error and the problem of causality in analysis of accidents. … , 2005 View More See More About The Topic Safety Scientists Error Analysis

142. The Veterans Affairs root cause analysis system in action. | PSNet
     psnet.ahrq.gov/issue/veterans-affairs-root-cause-analysis-system-action
     June 22, 2022 - Study Classic The Veterans Affairs root cause analysis … The Veterans Affairs Root Cause Analysis System in Action. … This article focuses on the application of root cause analysis (RCA) and the relationship between the … The Veterans Affairs Root Cause Analysis System in Action. … April 30, 2014 Root cause analysis reports help identify common factors in delayed diagnosis

143. Impact of an original methodological tool on the identification of corrective and preventive actions after root cause analysis of adverse events in health care facilities: results of a randomized controlled trial. | PSNet
     psnet.ahrq.gov/issue/impact-original-methodological-tool-identification-corrective-and-preventive-actions-after
     March 15, 2017 - original methodological tool on the identification of corrective and preventive actions after root cause analysis … Original Methodological Tool on the Identification of Corrective and Preventive Actions After Root Cause Analysis … Although root cause analysis of adverse events is a foundational patient safety activity, recent studies … November 7, 2018 Root cause analysis of cases involving diagnosis. … November 1, 2017 Root-cause analysis: swatting at mosquitoes versus draining the swamp

144. Root Cause Analysis: The Core of Problem Solving and Corrective Action, Second Edition. | PSNet
     psnet.ahrq.gov/issue/root-cause-analysis-core-problem-solving-and-corrective-action-second-edition
     June 09, 2011 - Book/Report Classic Root Cause Analysis: The Core of Problem … Citation Text: Root Cause Analysis: The Core of Problem Solving and Corrective Action, Second Edition … Root cause analysis is a widely used patient safety and quality improvement process for investigating … September 23, 2020 Root Cause Analysis in Health Care: A Joint Commission Guide to Analysis … September 2, 2016 A system analysis of a suboptimal surgical experience.

145. Wrong-side thoracentesis: lessons learned from root cause analysis. | PSNet
     psnet.ahrq.gov/issue/wrong-side-thoracentesis-lessons-learned-root-cause-analysis
     July 16, 2015 - Study Wrong-side thoracentesis: lessons learned from root cause analysis. … Wrong-side thoracentesis: lessons learned from root cause analysis. … This analysis of 14 cases of wrong-site thoracenteses, a procedure to remove fluid from around the lung … Root cause analysis of the errors found that clinicians often failed to perform a time out and did not … Wrong-side thoracentesis: lessons learned from root cause analysis.

146. Radiology failure mode and effect analysis: what is it? | PSNet
     psnet.ahrq.gov/issue/radiology-failure-mode-and-effect-analysis-what-it
     May 03, 2017 - Commentary Radiology failure mode and effect analysis: what is it? … Radiology failure mode and effect analysis: what is it? … This article introduces the concept of failure mode and effect analysis , outlines the process, and … Radiology failure mode and effect analysis: what is it? … analysis.

147. Key performance outcomes of patient safety curricula: root cause analysis, failure mode and effects analysis, and structured communications skills. | PSNet
     psnet.ahrq.gov/issue/key-performance-outcomes-patient-safety-curricula-root-cause-analysis-failure-mode-and
     July 23, 2010 - , failure mode and effects analysis, and structured communications skills. … Key performance outcomes of patient safety curricula: root cause analysis, failure mode and effects analysis … This commentary recommends that courses covering root cause analysis , failure mode and effects analysis … Key performance outcomes of patient safety curricula: root cause analysis, failure mode and effects analysis … Failure Mode Effects Analysis View More

148. Failure mode and effects analysis: an empirical comparison of failure mode scoring procedures. | PSNet
     psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-empirical-comparison-failure-mode-scoring-procedures
     January 03, 2017 - Study Failure mode and effects analysis: an empirical comparison of failure mode … Failure Mode and Effects Analysis. … Failure Mode and Effects Analysis. … An analysis of staff and patient survey data and routinely collected outcomes. … June 15, 2012 Health Care Failure Mode and Effect Analysis: a useful proactive risk analysis

149. The effectiveness of root cause analysis: what does the literature tell us? | PSNet
     psnet.ahrq.gov/issue/effectiveness-root-cause-analysis-what-does-literature-tell-us
     February 11, 2013 - Review The effectiveness of root cause analysis: what does the literature tell us … The effectiveness of root cause analysis: what does the literature tell us? … The effectiveness of root cause analysis: what does the literature tell us? … June 8, 2022 Does root cause analysis improve patient safety? … March 4, 2020 Root cause analysis for hospital-acquired pressure injury.

150. Evaluation of safety in a radiation oncology setting using failure mode and effects analysis. | PSNet
     psnet.ahrq.gov/issue/evaluation-safety-radiation-oncology-setting-using-failure-mode-and-effects-analysis
     January 22, 2017 - Evaluation of safety in a radiation oncology setting using failure mode and effects analysis … Evaluation of safety in a radiation oncology setting using failure mode and effects analysis. … Failure mode and effects analysis was used to prospectively analyze an external beam radiation therapy … Evaluation of safety in a radiation oncology setting using failure mode and effects analysis. … January 4, 2010 Radiology failure mode and effect analysis: what is it?

151. Analysis of unintended events in hospitals: inter-rater reliability of constructing causal trees and classifying root causes. | PSNet
     psnet.ahrq.gov/issue/analysis-unintended-events-hospitals-inter-rater-reliability-constructing-causal-trees-and
     April 30, 2014 - Study Analysis of unintended events in hospitals: inter-rater reliability of constructing … Analysis of unintended events in hospitals: inter-rater reliability of constructing causal trees and … Root cause analysis is commonly used to identify underlying system causes of adverse events. … Analysis of unintended events in hospitals: inter-rater reliability of constructing causal trees and … October 14, 2009 Unit-based incident reporting and root cause analysis: variation at

152. Building patient safety skills: common pitfalls when conducting a root cause analysis. | PSNet
     psnet.ahrq.gov/issue/building-patient-safety-skills-common-pitfalls-when-conducting-root-cause-analysis
     May 07, 2018 - Article Building patient safety skills: common pitfalls when conducting a root cause analysis … Citation Text: Building patient safety skills: common pitfalls when conducting a root cause analysis … January 29, 2020 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 Improving reliability with root cause analysis.

153. Adverse events during intrahospital transport of critically ill patients: a systematic review and meta-analysis. | PSNet
     psnet.ahrq.gov/issue/adverse-events-during-intrahospital-transport-critically-ill-patients-systematic-review-and
     March 02, 2022 - Adverse events during intrahospital transport of critically ill patients: a systematic review and meta-analysis … Adverse events during intrahospital transport of critically ill patients: A systematic review and meta-analysis … The authors conducted a systematic review and meta-analysis of all types of adverse events, critical … April 21, 2021 Evolving factors in hospital safety: a systematic review and meta-analysis … A systematic review and meta-analysis.

154. Engineering risk analysis of a hospital oxygen supply system. | PSNet
     psnet.ahrq.gov/issue/engineering-risk-analysis-hospital-oxygen-supply-system
     July 23, 2014 - Commentary Engineering risk analysis of a hospital oxygen supply system. … Engineering risk analysis of a hospital oxygen supply system. … Engineering risk analysis of a hospital oxygen supply system. … Analysis of 4 million outpatient prescriptions. … A systematic review and meta-analysis.

155. A review of the current evidence base for significant event analysis. | PSNet
     psnet.ahrq.gov/issue/review-current-evidence-base-significant-event-analysis
     October 14, 2009 - Review A review of the current evidence base for significant event analysis. … A review of the current evidence base for significant event analysis. … This review assessed research on the benefits and disadvantages of significant event analysis and identified … A review of the current evidence base for significant event analysis. … March 28, 2011 Meta-analysis: effect of interactive communication between collaborating

156. Analysis of reported drug interactions: a recipe for harm to patients. | PSNet
     psnet.ahrq.gov/issue/analysis-reported-drug-interactions-recipe-harm-patients
     January 20, 2016 - Newspaper/Magazine Article Analysis of reported drug interactions: a recipe for harm … Citation Text: Analysis of reported drug interactions: a recipe for harm to patients. … medication errors submitted over a 7-year period to the Pennsylvania Patient Safety Authority, this analysis … Linkedin Copy URL Cite Citation Citation Text: Analysis … April 17, 2017 Wrong-patient medication errors: an analysis of event reports in Pennsylvania

157. Developing a tool for assessing competency in root cause analysis. | PSNet
     psnet.ahrq.gov/issue/developing-tool-assessing-competency-root-cause-analysis
     May 01, 2014 - Study Developing a tool for assessing competency in root cause analysis. … Developing a tool for assessing competency in root cause analysis. … Root cause analysis (RCA) is being increasingly applied in health care systems to improve the quality … Developing a tool for assessing competency in root cause analysis. … March 18, 2020 Simulation-based event analysis improves error discovery and generates

158. Human factors in anaesthetic practice: insights from a task analysis. | PSNet
     psnet.ahrq.gov/issue/human-factors-anaesthetic-practice-insights-task-analysis
     April 18, 2011 - Study Human factors in anaesthetic practice: insights from a task analysis. … Human factors in anaesthetic practice: insights from a task analysis. … Human factors analysis of anesthesiologists' activities revealed several areas where the potential for … Human factors in anaesthetic practice: insights from a task analysis. … March 23, 2011 Litigation related to drug errors in anaesthesia: an analysis of claims

159. Applying hierarchical task analysis to medication administration errors. | PSNet
     psnet.ahrq.gov/issue/applying-hierarchical-task-analysis-medication-administration-errors
     December 18, 2017 - Commentary Applying hierarchical task analysis to medication administration errors … Applying hierarchical task analysis to medication administration errors. … Applying hierarchical task analysis to medication administration errors. … July 10, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis.

160. Root cause analysis of serious adverse events among older patients in the Veterans Health Administration. | PSNet
     psnet.ahrq.gov/issue/root-cause-analysis-serious-adverse-events-among-older-patients-veterans-health
     August 02, 2015 - Study Root cause analysis of serious adverse events among older patients in the Veterans … Root cause analysis of serious adverse events among older patients in the Veterans Health Administration … Root cause analysis of serious adverse events among older patients in the Veterans Health Administration … November 21, 2012 Root cause analysis of reported patient falls in ORs in the Veterans … of 227 root cause analysis reports in the Veterans Health Administration.