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281. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867652/psn-pdf
     February 26, 2025 - The Evolution of Root Cause Analysis February 26, 2025 Behrhorst J, Gale B, Van CM. … The Evolution of Root Cause Analysis. PSNet [internet]. 2025. … https://psnet.ahrq.gov/perspective/evolution-root-cause-analysis Introduction Root Cause Analysis ( … Using aggregate root cause analysis to improve patient safety. … Success Cause Analysis: Learning from what works to advance safety.

282. 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.

283. 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

284. 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

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 … https://psnet.ahrq.gov/issue/developing-implementing-evaluating-electronic-apparent-cause-analysis-across-health-care

286. 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

287. 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

288. 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

289. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47075/psn-pdf
     November 21, 2018 - Integrating systemic accident analysis into patient safety incident investigation practices. … Integrating systemic accident analysis into patient safety incident investigation practices. … https://psnet.ahrq.gov/issue/integrating-systemic-accident-analysis-patient-safety-incident-investigation … Systems Theoretic Accident Modelling and Processes (STAMP) analysis—for the same adverse event. … https://psnet.ahrq.gov/primer/root-cause-analysis https://psnet.ahrq.gov/primer/systems-approach

290. 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

291. 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

292. 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/

293. 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

294. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47508/psn-pdf
     October 24, 2018 - Root cause analysis of reported patient falls in ORs in the Veterans Health Administration. … Root Cause Analysis of Reported Patient Falls in ORs in the Veterans Health Administration. … https://psnet.ahrq.gov/issue/root-cause-analysis-reported-patient-falls-ors-veterans-health-administration … Root cause analysis has been widely promoted as a failure analysis tool for use in a variety of settings … https://psnet.ahrq.gov/perspective/rethinking-root-cause-analysis

295. 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.

296. 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

297. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/764390/psn-pdf
     March 02, 2022 - Does root cause analysis improve patient safety? … Does root cause analysis improve patient safety? … Root cause analysis (RCA) is a tool commonly used by organizations to analyze safety errors. … 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 … https://psnet.ahrq.gov/perspective/rethinking-root-cause-analysis

298. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60350/psn-pdf
     May 20, 2020 - Apparent cause analysis: a safety tool. May 20, 2020 Parikh K, Hochberg E, Cheng JJ, et al. … Apparent cause analysis: a safety tool. … https://psnet.ahrq.gov/issue/apparent-cause-analysis-safety-tool This article explores one hospital’ … s use of facilitated apparent cause analysis  (ACA), which is defined as a limited investigation of … https://psnet.ahrq.gov/issue/apparent-cause-analysis-safety-tool https://psnet.ahrq.gov/primer/root-cause-analysis

299. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/836784/psn-pdf
     March 23, 2022 - Qualitative content analysis: a framework for the substantive review of hospital incident reports. … Qualitative content analysis: a framework for the substantive review of hospital incident reports. … https://psnet.ahrq.gov/issue/qualitative-content-analysis-framework-substantive-review-hospital-incident … This article discusses the need for a standardized approach to incident report analysis and how qualitative … content analysis can support incident analysis and help identify risk mitigation strategies, performance

300. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/72546/psn-pdf
     December 09, 2020 - Analysis of incidents resulting in patient injuries in a web-based system in Swedish health care. … Analysis of incidents resulting in patient injuries in a web-based system in Swedish health care. … https://psnet.ahrq.gov/issue/learning-incident-reporting-analysis-incidents-resulting-patient-injuries-web … This analysis of incident reports occurring at one hospital in Sweden found that the handling, causes … https://psnet.ahrq.gov/primer/reporting-patient-safety-events https://psnet.ahrq.gov/primer/root-cause-analysis