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  1. psnet.ahrq.gov/issue/cost-benefit-analysis-support-program-nursing-staff
    October 26, 2016 - Study Classic Cost–benefit analysis of a support program … Cost-Benefit Analysis of a Support Program for Nursing Staff. … Cost-Benefit Analysis of a Support Program for Nursing Staff. … An analysis of associations with safety climate and working conditions. … October 21, 2010 Implementing a fatigue countermeasures program for nurses: a focus group analysis
  2. psnet.ahrq.gov/issue/comprehensive-analysis-medication-dosing-error-related-cpoe
    June 01, 2005 - Commentary Comprehensive analysis of a medication dosing error related to CPOE. … Comprehensive Analysis of a Medication Dosing Error Related to CPOE: Table 1. … Comprehensive Analysis of a Medication Dosing Error Related to CPOE: Table 1.
  3. psnet.ahrq.gov/issue/analysis-prescribers-notes-electronic-prescriptions-ambulatory-practice
    July 23, 2018 - Study Analysis of prescribers' notes in electronic prescriptions in ambulatory practice … Analysis of Prescribers' Notes in Electronic Prescriptions in Ambulatory Practice. … Analysis of Prescribers' Notes in Electronic Prescriptions in Ambulatory Practice. … July 23, 2018 Analysis of medication therapy discontinuation orders in new electronic … Cases A Mistaken Dose of Naloxone  December 18, 2019 Analysis
  4. psnet.ahrq.gov/issue/depth-analysis-medication-errors-hospitalized-patients-hiv
    July 15, 2010 - Study An in-depth analysis of medication errors in hospitalized patients with HIV … An in-depth analysis of medication errors in hospitalized patients with HIV. … An in-depth analysis of medication errors in hospitalized patients with HIV. … Department of Veterans Affairs: a qualitative analysis. … Identifying causes of adverse events detected by an automated trigger tool through in-depth analysis
  5. psnet.ahrq.gov/issue/content-analysis-team-communication-obstetric-emergency-scenario
    July 13, 2009 - Study Content analysis of team communication in an obstetric emergency scenario. … Content analysis of team communication in an obstetric emergency scenario. … Content analysis of team communication in an obstetric emergency scenario.
  6. psnet.ahrq.gov/issue/analysis-medication-prescribing-errors-critically-ill-children
    March 28, 2012 - Study Analysis of medication prescribing errors in critically ill children. … Analysis of medication prescribing errors in critically ill children. … Analysis of medication prescribing errors in critically ill children. … A post-hoc analysis of a before and after study.
  7. psnet.ahrq.gov/issue/serious-incidents-after-death-content-analysis-incidents-reported-national-database
    October 03, 2018 - Study Serious incidents after death: content analysis of incidents reported to a … Serious incidents after death: content analysis of incidents reported to a national database. … Serious incidents after death: content analysis of incidents reported to a national database. … August 25, 2021 A mixed-methods analysis of patient safety incidents involving opioid … July 18, 2016 Harms from discharge to primary care: mixed methods analysis of incident
  8. psnet.ahrq.gov/issue/missed-diagnosis-stroke-emergency-department-cross-sectional-analysis-large-population-based
    April 08, 2018 - Study Missed diagnosis of stroke in the emergency department: a cross-sectional analysis … Missed diagnosis of stroke in the emergency department: a cross-sectional analysis of a large population-based … Missed diagnosis of stroke in the emergency department: a cross-sectional analysis of a large population-based … with administrative claims data using Symptom-Disease Pair Analysis of Diagnostic Error methodology … June 19, 2018 Symptom–Disease Pair Analysis of Diagnostic Error (SPADE): a conceptual
  9. psnet.ahrq.gov/issue/nature-blame-patient-safety-incident-reports-mixed-methods-analysis-national-database
    October 12, 2016 - Study Nature of blame in patient safety incident reports: mixed methods analysis … Nature of Blame in Patient Safety Incident Reports: Mixed Methods Analysis of a National Database. … Nature of Blame in Patient Safety Incident Reports: Mixed Methods Analysis of a National Database. … April 1, 2020 Sources of unsafe primary care for older adults: a mixed-methods analysis … September 24, 2017 A mixed-methods analysis of patient safety incidents involving opioid
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33568/psn-pdf
    June 15, 2024 - Root Cause Analysis June 15, 2024 Root Cause Analysis. PSNet [internet]. 2019. … https://psnet.ahrq.gov/primer/root-cause-analysis https://psnet.ahrq.gov/issue/cross-sectional-study-relationship-between-utilization-root-cause-analysis-and-patient-safety … 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 … https://psnet.ahrq.gov/perspective/rethinking-root-cause-analysis https://psnet.ahrq.gov/issue/tool-concise-analysis-patient-safety-incidents
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/844791/psn-pdf
    September 18, 2019 - 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 … - report-analysis Root cause analysis is a fundamental approach to understanding how failures occur … https://psnet.ahrq.gov/issue/review-alternatives-root-cause-analysis-developing-robust-system-incident-report-analysis … https://psnet.ahrq.gov/issue/review-alternatives-root-cause-analysis-developing-robust-system-incident-report-analysis
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47096/psn-pdf
    November 14, 2018 - analysis system. … Analysis System. … - cause-analysis This analysis of the Veterans Health Administration root cause analysis database identified … https://psnet.ahrq.gov/issue/analysis-adverse-events-rehabilitation-department-using-veterans-affairs-root-cause-analysis … https://psnet.ahrq.gov/issue/analysis-adverse-events-rehabilitation-department-using-veterans-affairs-root-cause-analysis
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/859350/psn-pdf
    December 20, 2023 - What are the experiences of team members involved in root cause analysis? A qualitative study. … What are the experiences of team members involved in root cause analysis? A qualitative study. … https://psnet.ahrq.gov/issue/what-are-experiences-team-members-involved-root-cause-analysis-qualitative … https://psnet.ahrq.gov/primer/root-cause-analysis https://psnet.ahrq.gov/issue/our-current-approach-root-cause-analysis-it-contributing-our-failure-improve-patient-safety … https://psnet.ahrq.gov/perspective/rethinking-root-cause-analysis
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867596/psn-pdf
    January 22, 2025 - Creation of root cause analysis and action (RCA2) standard work by a multidisciplinary team to prevent … Creation of root cause analysis and action (RCA2) standard work by a multidisciplinary team to prevent … - team-prevent Root cause analysis (RCA) is a common strategy to investigate patient safety events … This article describes the implementation of a root cause analysis and action (RCA2) framework in a … https://psnet.ahrq.gov/issue/problem-root-cause-analysis https://psnet.ahrq.gov/issue/implementing-root-cause-analysis-and-action-integrating-human-factors-create-strong
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866907/psn-pdf
    October 09, 2024 - A review of modifiable health care factors contributing to inpatient suicide: an analysis of coroners … ' reports using the Human Factors Analysis and Classification System for Healthcare October 9, 2024 … A review of modifiable health care factors contributing to inpatient suicide: an analysis of coroners … ' reports using the Human Factors Analysis and Classification System for Healthcare. … Using data from 2009 to 2018, researchers used the Human Factors Analysis and Classification System
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45953/psn-pdf
    July 22, 2020 - Root Cause Analysis in Health Care: A Joint Commission Guide to Analysis and Corrective Action of Sentinel … https://psnet.ahrq.gov/issue/root-cause-analysis-health-care-joint-commission-guide-analysis-and- corrective-action … https://psnet.ahrq.gov/issue/root-cause-analysis-health-care-joint-commission-guide-analysis-and-corrective-action … https://psnet.ahrq.gov/issue/root-cause-analysis-health-care-joint-commission-guide-analysis-and-corrective-action … https://psnet.ahrq.gov/primer/root-cause-analysis https://psnet.ahrq.gov/issue/root-cause-analysis-swatting-mosquitoes-versus-draining-swamp
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837335/psn-pdf
    June 08, 2022 - 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 … https://psnet.ahrq.gov/issue/root-cause-analysis-using-prevention-and-recovery-information-system- monitoring-and-analysis … https://psnet.ahrq.gov/issue/root-cause-analysis-using-prevention-and-recovery-information-system-monitoring-and-analysis … https://psnet.ahrq.gov/issue/root-cause-analysis-using-prevention-and-recovery-information-system-monitoring-and-analysis
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60968/psn-pdf
    September 30, 2020 - 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 … https://psnet.ahrq.gov/issue/assisting-beginners-root-cause-analysis-operations-analysis-and- recommendations-regarding … https://psnet.ahrq.gov/issue/assisting-beginners-root-cause-analysis-operations-analysis-and-recommendations-regarding … https://psnet.ahrq.gov/issue/assisting-beginners-root-cause-analysis-operations-analysis-and-recommendations-regarding
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867634/psn-pdf
    February 26, 2025 - Using simulation to augment root cause analysis for patient safety incidents at a tertiary care women's … Using simulation to augment root cause analysis for patient safety incidents at a tertiary care women's … https://psnet.ahrq.gov/issue/using-simulation-augment-root-cause-analysis-patient-safety-incidents-tertiary … - care-womens Root cause analysis (RCA) is a common investigation technique in healthcare. … https://psnet.ahrq.gov/primer/root-cause-analysis https://psnet.ahrq.gov/issue/using-simulation-improve-root-cause-analysis-adverse-surgical-outcomes
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/856590/psn-pdf
    November 29, 2023 - Team experiences of the root cause analysis process after a sentinel event: a qualitative case study … Team experiences of the root cause analysis process after a sentinel event: a qualitative case study … https://psnet.ahrq.gov/issue/team-experiences-root-cause-analysis-process-after-sentinel-event-qualitative … - case-study Root cause analysis (RCA) is a frequently used, and sometimes mandatory, method to investigate … https://psnet.ahrq.gov/perspective/rethinking-root-cause-analysis https://psnet.ahrq.gov/issue/root-cause-analysis-health-care-joint-commission-guide-analysis-and-corrective-action

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