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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

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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 … June 28, 2013 Root cause analysis of cases involving diagnosis. … November 1, 2017 Root-cause analysis: swatting at mosquitoes versus draining the swamp

Root Cause Analysis: The Core of Problem Solving and Corrective Action, Second Edition. | PSNet

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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.

Wrong-side thoracentesis: lessons learned from root cause analysis. | PSNet

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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.

Failure mode and effects analysis: an empirical comparison of failure mode scoring procedures. | PSNet

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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

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?

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.

Primary medication non-adherence: analysis of 195,930 electronic prescriptions. | PSNet

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July 27, 2016 - Study Primary medication non-adherence: analysis of 195,930 electronic prescriptions … Primary medication non-adherence: analysis of 195,930 electronic prescriptions. … In this analysis of nearly 200,000 electronic prescriptions, more than 20% were not filled by the patient … Primary medication non-adherence: analysis of 195,930 electronic prescriptions. … Related Resources Medication adverse events in the ambulatory setting: a mixed-methods analysis

Analysis of unintended events in hospitals: inter-rater reliability of constructing causal trees and classifying root causes. | PSNet

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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

Building patient safety skills: common pitfalls when conducting a root cause analysis. | PSNet

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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.

FMEA team performance in health care: a qualitative analysis of team member perceptions. | PSNet

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December 31, 2014 - Study FMEA team performance in health care: a qualitative analysis of team member … Failure mode and effect analysis (FMEA), a tool that allows prospective risk assessment, has been … December 18, 2013 Using failure mode and effects analysis to plan implementation of smart … May 19, 2015 Prospective risk analysis and incident reporting for better pharmaceutical … December 15, 2010 Is failure mode and effect analysis reliable?

Using root cause analysis to reduce falls with injury in community settings. | PSNet

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April 25, 2016 - Study Using root cause analysis to reduce falls with injury in community settings … Using root cause analysis to reduce falls with injury in community settings. … This study used root cause analysis (RCA) to identify hazards leading to falls among community-dwelling … Using root cause analysis to reduce falls with injury in community settings. … April 25, 2016 Wrong-side thoracentesis: lessons learned from root cause analysis.

Failure mode and effects analysis: a comparison of two common risk prioritisation methods. | PSNet

psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-comparison-two-common-risk-prioritisation-methods

September 09, 2015 - Study Failure mode and effects analysis: a comparison of two common risk prioritisation … Failure mode and effects analysis: a comparison of two common risk prioritisation methods. … Comparing a traditional resource-intensive FMEA with a simplified version, this analysis found that the … Failure mode and effects analysis: a comparison of two common risk prioritisation methods. … June 9, 2021 Root Cause Analysis in Health Care: A Joint Commission Guide to Analysis

Root cause analysis of reported patient falls in ORs in the Veterans Health Administration. | PSNet

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January 17, 2019 - Commentary Root cause analysis of reported patient falls in ORs in the Veterans Health … Root Cause Analysis of Reported Patient Falls in ORs in the Veterans Health Administration. … Root cause analysis has been widely promoted as a failure analysis tool for use in a variety of settings … Root Cause Analysis of Reported Patient Falls in ORs in the Veterans Health Administration. … August 21, 2013 Wrong-side thoracentesis: lessons learned from root cause analysis.

Analysis of reported drug interactions: a recipe for harm to patients. | PSNet

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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

Root cause analysis and actions for the prevention of medical errors: quality improvement and resident education. | PSNet

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October 19, 2016 - Commentary Root cause analysis and actions for the prevention of medical errors: … Root Cause Analysis and Actions for the Prevention of Medical Errors: Quality Improvement and Resident … This commentary highlights the importance of engaging residents in root cause analysis of errors … The authors discuss how participation in root cause analysis can educate trainees about process analysis … October 18, 2023 The Veterans Affairs root cause analysis system in action.

Applying principles from aviation safety investigations to root cause analysis of a critical incident during a simulated emergency. | PSNet

psnet.ahrq.gov/issue/applying-principles-aviation-safety-investigations-root-cause-analysis-critical-incident

July 27, 2016 - Study Applying principles from aviation safety investigations to root cause analysis … Applying principles from aviation safety investigations to root cause analysis of a critical incident … This case study describes the use of root cause analysis t o investigate a critical incident occurring … Applying principles from aviation safety investigations to root cause analysis of a critical incident … program using root cause analysis and common cause analysis.

Using Healthcare Failure Mode and Effect Analysis to reduce medication errors in the process of drug prescription, validation and dispensing in hospitalised patients. | PSNet

psnet.ahrq.gov/issue/using-healthcare-failure-mode-and-effect-analysis-reduce-medication-errors-process-drug

August 23, 2017 - Study Using Healthcare Failure Mode and Effect Analysis to reduce medication errors … Using Healthcare Failure Mode and Effect Analysis to reduce medication errors in the process of drug … Using Healthcare Failure Mode and Effect Analysis to reduce medication errors in the process of drug … May 11, 2014 Augmenting health care failure modes and effects analysis with simulation … February 1, 2013 Failure mode and effects analysis outputs: are they valid?

Risks and medication errors analysis to evaluate the impact of a chemotherapy compounding workflow management system on cancer patients' safety. | PSNet

psnet.ahrq.gov/issue/risks-and-medication-errors-analysis-evaluate-impact-chemotherapy-compounding-workflow

January 27, 2019 - Study Risks and medication errors analysis to evaluate the impact of a chemotherapy … Risks and medication errors analysis to evaluate the impact of a chemotherapy compounding workflow management … This study applied failure mode, effect, and criticality analysis (FMECA) methodology to identify … February 20, 2019 Using Failure Mode and Effects Analysis for safe administration of … May 27, 2011 Health Care Failure Mode and Effect Analysis: a useful proactive risk analysis

Adverse respiratory events in anesthesia: a closed claims analysis. | PSNet

psnet.ahrq.gov/issue/adverse-respiratory-events-anesthesia-closed-claims-analysis

February 10, 2011 - Classic Adverse respiratory events in anesthesia: a closed claims analysis … Adverse respiratory events in anesthesia: a closed claims analysis. … A retrospective analysis of the American Society of Anesthesiology Closed Claims Study, this article … Adverse respiratory events in anesthesia: a closed claims analysis. … July 13, 2010 Management of the difficult airway: a closed claims analysis.

Rapid response teams: a systematic review and meta-analysis. | PSNet

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December 21, 2014 - Classic Rapid response teams: a systematic review and meta-analysis … Rapid Response Teams: A Systematic Review and Meta-analysis. … However, this systematic review and meta-analysis found no definitive evidence that the teams improved … Rapid Response Teams: A Systematic Review and Meta-analysis. … October 3, 2011 A 5-year analysis of rapid response system activation at an in-hospital

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