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21. Quantitative analysis of adverse events in neurosurgery. | PSNet
    psnet.ahrq.gov/issue/quantitative-analysis-adverse-events-neurosurgery
    September 25, 2019 - Study Quantitative analysis of adverse events in neurosurgery. … Quantitative analysis of adverse events in neurosurgery. … Analysis of cases from neurosurgery morbidity and mortality conferences found that while the overall … Quantitative analysis of adverse events in neurosurgery. … July 22, 2015 Disorganized care: the findings of an iterative, in-depth analysis of surgical

22. Root Cause Analysis in Health Care: A Joint Commission Guide to Analysis and Corrective Action of Sentinel and Adverse Events. | PSNet
    psnet.ahrq.gov/issue/root-cause-analysis-health-care-joint-commission-guide-analysis-and-corrective-action
    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

23. 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

24. Nurse well-being: a concept analysis. | PSNet
    psnet.ahrq.gov/issue/nurse-well-being-concept-analysis
    August 25, 2021 - Study Nurse well-being: a concept analysis. … Nurse well-being: a concept analysis. … In this study, researchers used a concept analysis to identify attributes of nurse well-being at the … Nurse well-being: a concept analysis. … Surgeon burnout, impact on patient safety and professionalism: a systematic review and meta-analysis

25. Time out: an analysis. | PSNet
    psnet.ahrq.gov/issue/time-out-analysis
    October 19, 2022 - Commentary Time out: an analysis. Citation Text: Dillon KA. … Time out: an analysis. AORN J. 2008;88(3):437-442. doi:10.1016/j.aorn.2008.03.003. … Time out: an analysis. AORN J. 2008;88(3):437-442. doi:10.1016/j.aorn.2008.03.003. … structure and construct validity of a hospital survey on patient safety culture using exploratory factor analysis

26. Intimidation: a concept analysis. | PSNet
    psnet.ahrq.gov/issue/intimidation-concept-analysis
    May 20, 2020 - Review Intimidation: a concept analysis. … Intimidation: a concept analysis. … Intimidation: a concept analysis. … May 20, 2020 Analysis of staff safety concerns. … A quality improvement project and difference-in-difference analysis.

27. Fluorouracil Incident Root Cause Analysis Report. | PSNet
    psnet.ahrq.gov/issue/fluorouracil-incident-root-cause-analysis-report
    September 02, 2014 - Citation Text: Fluorouracil Incident Root Cause Analysis Report. … 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 2, 2018 ISMP medication error report analysis.

28. Healthcare Failure Mode and Effect Analysis. | PSNet
    psnet.ahrq.gov/issue/healthcare-failure-mode-and-effect-analysis
    May 24, 2017 - Toolkit Healthcare Failure Mode and Effect Analysis. … Citation Text: Healthcare Failure Mode and Effect Analysis. … These materials provide an introduction to the purpose of healthcare failure mode and effect analysis … September 1, 2021 Using Health Care Failure Mode and Effect Analysis: the VA National … Center for Patient Safety's prospective risk analysis system.

29. Apparent cause analysis: a safety tool. | PSNet
    psnet.ahrq.gov/issue/apparent-cause-analysis-safety-tool
    June 27, 2018 - Study Apparent cause analysis: a safety tool. … Apparent cause analysis: a safety tool. … This article explores one hospital’s use of facilitated apparent cause analysis  (ACA), which is defined … The article compares ACA versus root cause analysis   and describes the process for completing facilitated … Apparent cause analysis: a safety tool.

30. Drill down with root cause analysis. | PSNet
    psnet.ahrq.gov/issue/drill-down-root-cause-analysis
    June 15, 2016 - Commentary Drill down with root cause analysis. … Drill down with root cause analysis. Nurs Manage. 2005;36(10):26-32. … program using root cause analysis and common cause analysis. … March 2, 2022 Assisting beginners in root cause analysis operations: analysis and recommendations … July 19, 2010 Random safety auditing, root cause analysis, failure mode and effects analysis

31. Improving reliability with root cause analysis. | PSNet
    psnet.ahrq.gov/issue/improving-reliability-root-cause-analysis
    January 17, 2017 - Newspaper/Magazine Article Improving reliability with root cause analysis. … Citation Text: Improving reliability with root cause analysis. … This article relates how root cause analysis , typically used after an adverse event, can be utilized … to Analysis and Corrective Action of Sentinel and Adverse Events. … September 14, 2016 Wrong-side thoracentesis: lessons learned from root cause analysis

32. Special Section: Event Analysis and Risk Management. | PSNet
    psnet.ahrq.gov/issue/special-section-event-analysis-and-risk-management
    March 11, 2020 - Book/Report Special Section: Event Analysis and Risk Management. … Citation Text: Special Section: Event Analysis and Risk Management. Alemi F ed. … Adverse event analysis is core for organizational learning from poor performance. … This special section discusses how examination tools such as failure mode and effect analysis and root … cause analysis may be amended to optimize how lessons can be drawn from failure to inform improvement

33. Is failure mode and effect analysis reliable? | PSNet
    psnet.ahrq.gov/issue/failure-mode-and-effect-analysis-reliable
    August 15, 2012 - Study Is failure mode and effect analysis reliable? … Is failure mode and effect analysis reliable? … Failure mode and effect analysis (FMEA) is a widely used tool for hazard analysis. … Is failure mode and effect analysis reliable? … May 10, 2013 Failure mode and effects analysis outputs: are they valid?

34. A system analysis of a suboptimal surgical experience. | PSNet
    psnet.ahrq.gov/issue/system-analysis-suboptimal-surgical-experience
    March 23, 2011 - Study A system analysis of a suboptimal surgical experience. … A system analysis of a suboptimal surgical experience. … A system analysis of a suboptimal surgical experience. … Interview In Conversation with Jessica Behrhorst about The Evolution of Root Cause Analysis … 27, 2024 Investigation of urology intraoperative events leading to root cause analysis

35. Systems analysis of adverse drug events. | PSNet
    psnet.ahrq.gov/issue/systems-analysis-adverse-drug-events
    February 10, 2011 - Study Classic Systems analysis of adverse drug events. … Systems analysis of adverse drug events. ADE Prevention Study Group. JAMA. 1995;274(1):35-43. … The authors report a "systems analysis" of the adverse drug events (ADEs) detected in their seminal … The authors report their analysis of the underlying, or "system," causes of the ADEs as distinct from … Systems analysis of adverse drug events. ADE Prevention Study Group. JAMA. 1995;274(1):35-43.

36. Perception of feeling safe perioperatively: a concept analysis. | PSNet
    psnet.ahrq.gov/issue/perception-feeling-safe-perioperatively-concept-analysis
    December 21, 2022 - Review Perception of feeling safe perioperatively: a concept analysis. … Perception of feeling safe perioperatively: a concept analysis. … This concept analysis describes defining attributes (participation, control, presence) of patients … Perception of feeling safe perioperatively: a concept analysis. … November 15, 2023 Team experiences of the root cause analysis process after a sentinel

37. 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

38. Experience feedback committees: a way of implementing a root cause analysis practice in hospital medical departments. | PSNet
    psnet.ahrq.gov/issue/experience-feedback-committees-way-implementing-root-cause-analysis-practice-hospital-medical
    October 30, 2024 - Study Experience feedback committees: a way of implementing a root cause analysis … Experience feedback committees: A way of implementing a root cause analysis practice in hospital medical … An Annual Perspective discussed the limitations of root cause analysis and how this tool can be improved … Experience feedback committees: A way of implementing a root cause analysis practice in hospital medical … November 1, 2017 Root-cause analysis: swatting at mosquitoes versus draining the swamp

39. Root cause analysis of cases involving diagnosis. | PSNet
    psnet.ahrq.gov/issue/root-cause-analysis-cases-involving-diagnosis
    August 28, 2019 - Commentary Root cause analysis of cases involving diagnosis. … Root cause analysis of cases involving diagnosis. … Root cause analysis (RCA) is a widely used approach to retrospectively analyze safety events like surgical … Root cause analysis of cases involving diagnosis.

40. Human reliability analysis: a critique and review for managers. | PSNet
    psnet.ahrq.gov/issue/human-reliability-analysis-critique-and-review-managers
    November 21, 2021 - Review Human reliability analysis: a critique and review for managers. … Human reliability analysis: A critique and review for managers. … This review discusses how human reliability analysis methodologies can be developed to improve safety … Human reliability analysis: A critique and review for managers. … Interview In Conversation with Jessica Behrhorst about The Evolution of Root Cause Analysis