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281. 2024 Network of Patient Safety Databases Chartbook: Medication and Other Substance Events. | PSNet
     psnet.ahrq.gov/issue/2024-network-patient-safety-databases-chartbook-medication-and-other-substance-events
     September 11, 2024 - June 16, 2019 ISMP medication error report 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. … June 16, 2019 ISMP medication error report analysis.

282. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60526/psn-pdf
     May 27, 2020 - 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 … - analysis Based on 31 root cause analysis reports of surgical incidents in Australia, this study found … https://psnet.ahrq.gov/issue/qualitative-content-analysis-retained-surgical-items-learning-root-cause-analysis … https://psnet.ahrq.gov/issue/qualitative-content-analysis-retained-surgical-items-learning-root-cause-analysis

283. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866731/psn-pdf
     September 18, 2024 - Root cause analysis of cases involving diagnosis. … Root cause analysis of cases involving diagnosis. … https://psnet.ahrq.gov/issue/root-cause-analysis-cases-involving-diagnosis Root cause analysis (RCA) … https://psnet.ahrq.gov/issue/root-cause-analysis-cases-involving-diagnosis https://psnet.ahrq.gov/primer … /root-cause-analysis https://psnet.ahrq.gov/issue/thinking-fast-and-slow-medicine https://psnet.ahrq.gov

284. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/862129/psn-pdf
     February 07, 2024 - Application of "Human Factor Analysis and Classification System" (HFACS) model to the prevention of … https://psnet.ahrq.gov/issue/application-human-factor-analysis-and-classification-system-hfacs-model- … prevention-medical Human Factor Analysis and Classification System (HFACS) in healthcare is used to … This review found 12 studies that used HFACS for coding, cause analysis, and categorization of adverse … https://psnet.ahrq.gov/issue/human-factors-analysis-classification-system-hfacs-applied-health-care

285. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866527/psn-pdf
     August 14, 2024 - Developing, implementing, evaluating electronic apparent cause analysis across a health care system. … Developing, implementing, evaluating electronic apparent cause analysis across a health care system. … https://psnet.ahrq.gov/issue/developing-implementing-evaluating-electronic-apparent-cause-analysis- … This article describes the development of an electronic apparent cause analysis (eACA) tool, which combines … https://psnet.ahrq.gov/issue/developing-implementing-evaluating-electronic-apparent-cause-analysis-across-health-care

286. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/48134/psn-pdf
     August 14, 2019 - Root cause analysis for hospital-acquired pressure injury. August 14, 2019 Black JM. … Root cause analysis for hospital-acquired pressure injury. … https://psnet.ahrq.gov/issue/root-cause-analysis-hospital-acquired-pressure-injury Pressure injuries … The author suggests that common cause analysis is an effective method to utilize root cause analysis … /psnet.ahrq.gov/issue/common-cause-analysis

287. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/865817/psn-pdf
     May 08, 2024 - Using Healthcare Failure Mode and Effect Analysis in prospective medication safety risk management in … Using Healthcare Failure Mode and Effect Analysis in prospective medication safety risk management in … https://psnet.ahrq.gov/issue/using-healthcare-failure-mode-and-effect-analysis-prospective-medication … In this study, a hospital used Healthcare Failure Mode and Effect Analysis (HFMEA) to prospectively … https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-reduce-risk-heparin-use https://psnet.ahrq.gov

288. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866082/psn-pdf
     June 05, 2024 - Putting the "action" in RCA(2): an analysis of intervention strength after adverse events. … Putting the "action" in RCA(2): an analysis of intervention strength after adverse events. … https://psnet.ahrq.gov/issue/putting-action-rca2-analysis-intervention-strength-after-adverse-events … This analysis of 67 safety events reported at one academic medical center between 2020 and 2021 explored … https://psnet.ahrq.gov/issue/putting-action-rca2-analysis-intervention-strength-after-adverse-events

289. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866271/psn-pdf
     July 10, 2024 - A taxonomy for advancing systematic error analysis in multi-site electronic health record-based clinical … A taxonomy for advancing systematic error analysis in multi-site electronic health record-based clinical … https://psnet.ahrq.gov/issue/taxonomy-advancing-systematic-error-analysis-multi-site-electronic-health … record-based Standardized taxonomies allow for consistency across settings and enhance research and analysis … https://psnet.ahrq.gov/issue/taxonomy-advancing-systematic-error-analysis-multi-site-electronic-health-record-based

290. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73371/psn-pdf
     June 09, 2021 - Reducing failures in daily medical practice: healthcare failure mode and effect analysis combined with … Reducing failures in daily medical practice: healthcare failure mode and effect analysis combined with … Failure mode and effect analysis (FMEA) is widely used to identify latent safety hazards. … The authors of this study proposed combining healthcare failure mode and effect analysis (HFMEA) with … https://psnet.ahrq.gov/issue/augmenting-health-care-failure-modes-and-effects-analysis-simulation https

291. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46606/psn-pdf
     July 10, 2019 - Implementation of a mock root cause analysis to provide simulated patient safety training. … Implementation of a mock root cause analysis to provide simulated patient safety training. … https://psnet.ahrq.gov/issue/implementation-mock-root-cause-analysis-provide-simulated-patient-safety … - training Root cause analysis is a strategy to identify and reduce risks, but there are concerns regarding … 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

292. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/856584/psn-pdf
     January 01, 2024 - Patient safety incidents in endoscopy: a human factors analysis of non-procedural significant harm incidents … Patient safety incidents in endoscopy: a human factors analysis of nonprocedural significant harm incidents … https://psnet.ahrq.gov/issue/patient-safety-incidents-endoscopy-human-factors-analysis-non-procedural … Based on Human Factors Analysis and Classification System coding, decision-based errors were the most … https://psnet.ahrq.gov/issue/human-factors-analysis-classification-system-hfacs-applied-health-care

293. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/849317/psn-pdf
     May 24, 2023 - Implementing an electronic root cause analysis reporting system to decrease hospital-acquired pressure … Implementing an electronic root cause analysis reporting system to decrease hospital- acquired pressure … https://psnet.ahrq.gov/issue/implementing-electronic-root-cause-analysis-reporting-system-decrease- … A root cause analysis was completed for each HAPI to identify trends and implement improvements. … https://psnet.ahrq.gov/issue/root-cause-analysis-hospital-acquired-pressure-injury

294. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/837200/psn-pdf
     May 25, 2022 - 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. … https://psnet.ahrq.gov/issue/analysis-readmissions-mobile-integrated-health-transitional-care-program

295. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73462/psn-pdf
     July 07, 2021 - Root cause analysis to identify contributing factors for the development of hospital acquired pressure … Root cause analysis to identify contributing factors for the development of hospital acquired pressure … https://psnet.ahrq.gov/issue/root-cause-analysis-identify-contributing-factors-development-hospital- … Through root cause analysis, this geriatric rehabilitation hospital identified factors that contributed … /primer/root-cause-analysis https://psnet.ahrq.gov/primer/root-cause-analysis https://psnet.ahrq.gov/

296. An observational study of how patients are identified before medication administrations in medical and surgical wards. | PSNet
     psnet.ahrq.gov/issue/observational-study-how-patients-are-identified-medication-administrations-medical-and
     June 24, 2020 - June 24, 2020 ISMP medication error report 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. … June 16, 2019 ISMP medication error report analysis.

297. Using preprinted medication order forms to improve the safety of investigational drug use. | PSNet
     psnet.ahrq.gov/issue/using-preprinted-medication-order-forms-improve-safety-investigational-drug-use
     April 24, 2024 - June 16, 2019 ISMP medication error report 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. … June 16, 2019 ISMP medication error report analysis.

298. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/865977/psn-pdf
     May 29, 2024 - Complication rates of central venous catheters: a systematic review and meta-analysis. … Complication rates of central venous catheters: a systematic review and meta-analysis. … https://psnet.ahrq.gov/issue/complication-rates-central-venous-catheters-systematic-review-and-meta- analysis … This meta-analysis estimated that approximately 3% of patients who have a CVC for three days experience … https://psnet.ahrq.gov/issue/complication-rates-central-venous-catheters-systematic-review-and-meta-analysis

299. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867179/psn-pdf
     January 01, 2025 - Implementation of a standardized tool for root cause analysis selection. … Implementation of a standardized tool for root cause analysis selection. … https://psnet.ahrq.gov/issue/implementation-standardized-tool-root-cause-analysis-selection The root … cause analysis or RCA2 framework is a standardized approach to identify patient safety incidents based … In this study, researchers used an RCA2 algorithm to identify high-risk events for root cause analysis

300. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866251/psn-pdf
     July 10, 2024 - A systematic review and meta-analysis of artificial intelligence versus clinicians for skin cancer diagnosis … A systematic review and meta-analysis of artificial intelligence versus clinicians for skin cancer diagnosis … https://psnet.ahrq.gov/issue/systematic-review-and-meta-analysis-artificial-intelligence-versus-clinicians … This systematic review and meta-analysis of 19 studies found that AI algorithms for skin cancer classification … https://psnet.ahrq.gov/issue/systematic-review-and-meta-analysis-artificial-intelligence-versus-clinicians-skin-cancer