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301. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866192/psn-pdf
     June 26, 2024 - A systemwide strategy to embed equity into patient safety event analysis. … A systemwide strategy to embed equity into patient safety event analysis. … https://psnet.ahrq.gov/issue/systemwide-strategy-embed-equity-patient-safety-event-analysis Root cause … analysis (RCA) investigations are conducted to identify systemic issues that contributed to an adverse … /primer/root-cause-analysis https://psnet.ahrq.gov/issue/bringing-equity-lens-patient-safety-event-reporting

302. 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

303. 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

304. 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

305. 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

306. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/844777/psn-pdf
     September 18, 2019 - Adapting cognitive task analysis to investigate clinical decision making and medication safety incidents … Adapting Cognitive Task Analysis to Investigate Clinical Decision Making and Medication Safety Incidents … https://psnet.ahrq.gov/issue/adapting-cognitive-task-analysis-investigate-clinical-decision-making-and … - medication-safety Cognitive task analysis is a human factors engineering method used to evaluate … This study examined medication safety through the lens of cognitive task analysis and concluded that

307. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73113/psn-pdf
     April 07, 2021 - Analysis of results from event investigations in industrial and patient safety contexts. … Analysis of results from event investigations in industrial and patient safety contexts. … The primary purpose of incident reporting and analysis is to propose safety reforms. … In-depth analysis resulted in more suggestions for reform targeted at the federal, regional, health … Root cause analysis resulted in suggestions at the department or ward level.

308. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/48076/psn-pdf
     July 24, 2019 - Simulation-based event analysis improves error discovery and generates improved strategies for error … Simulation-based event analysis improves error discovery and generates improved strategies for error … https://psnet.ahrq.gov/issue/simulation-based-event-analysis-improves-error-discovery-and-generates- … improved-strategies Root cause analysis (RCA) is a vital tool to assess errors and prevent their recurrence … https://psnet.ahrq.gov/issue/effectiveness-and-efficiency-root-cause-analysis-medicine

309. Interventions to reduce medication dispensing, administration, and monitoring errors in pediatric professional healthcare settings: a systematic review. | PSNet
     psnet.ahrq.gov/issue/interventions-reduce-medication-dispensing-administration-and-monitoring-errors-pediatric
     June 23, 2021 - July 22, 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.

310. Proceedings of a summit on preventing patient harm and death from IV medication errors. | PSNet
     psnet.ahrq.gov/issue/proceedings-summit-preventing-patient-harm-and-death-iv-medication-errors
     June 16, 2019 - 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.

311. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/848360/psn-pdf
     May 03, 2023 - Optimizing measurement of misdiagnosis-related harms using symptom-disease pair analysis of diagnostic … Optimizing measurement of misdiagnosis-related harms using symptom-disease pair analysis of diagnostic … psnet.ahrq.gov/issue/optimizing-measurement-misdiagnosis-related-harms-using-symptom-disease- pair-analysis … Symptom–Disease Pair Analysis of Diagnostic Error (SPADE) is a framework to measure diagnostic errors … comparator groups, how to select the appropriate group, and what inferences can be drawn from the analysis

312. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/61031/psn-pdf
     October 14, 2020 - Special Section: Event Analysis and Risk Management. October 14, 2020 Alemi F ed. … https://psnet.ahrq.gov/issue/special-section-event-analysis-and-risk-management Adverse event analysis … 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 … https://psnet.ahrq.gov/issue/special-section-event-analysis-and-risk-management https://psnet.ahrq.gov

313. Patient engagement in health care safety: an overview of mixed-quality evidence. | PSNet
     psnet.ahrq.gov/issue/patient-engagement-health-care-safety-overview-mixed-quality-evidence
     October 21, 2020 - Analysis of incident reports from a patient safety organization. … 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.

314. Lack of standard dosing methods contributes to IV errors. | PSNet
     psnet.ahrq.gov/issue/lack-standard-dosing-methods-contributes-iv-errors
     December 07, 2022 - 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.

315. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/74099/psn-pdf
     January 01, 2022 - Hemodialysis bleeding events and deaths: an 18-year retrospective analysis of patient safety and root … cause analysis reports in the Veterans Health Administration. … Hemodialysis bleeding events and deaths: an 18-year retrospective analysis of patient safety and root … cause analysis reports in the Veterans Health Administration. … https://psnet.ahrq.gov/issue/hemodialysis-bleeding-events-and-deaths-18-year-retrospective-analysis-

316. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/845637/psn-pdf
     March 08, 2023 - Using Failure Mode, Effect and Criticality Analysis to improve safety in the cancer treatment prescription … Using Failure Mode, Effect and Criticality Analysis to improve safety in the cancer treatment prescription … https://psnet.ahrq.gov/issue/using-failure-mode-effect-and-criticality-analysis-improve-safety-cancer … - treatment Failure Mode, Effect and Criticality Analysis (FMECA) is a prospective method for identifying … https://psnet.ahrq.gov/issue/using-failure-mode-effect-and-criticality-analysis-improve-safety-cancer-treatment

317. Your attention please... designing effective warnings. | PSNet
     psnet.ahrq.gov/issue/your-attention-please-designing-effective-warnings
     March 14, 2023 - 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.

318. The safety of intravenous drug delivery systems: update on current issues since the 1999 Consensus Development Conference. | PSNet
     psnet.ahrq.gov/issue/safety-intravenous-drug-delivery-systems-update-current-issues-1999-consensus-development
     May 13, 2020 - 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.

319. Pharmacy mixes up prescriptions. | PSNet
     psnet.ahrq.gov/issue/pharmacy-mixes-prescriptions
     March 10, 2021 - 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.

320. Infusion medication error reduction by two-person verification: a quality improvement initiative. | PSNet
     psnet.ahrq.gov/issue/infusion-medication-error-reduction-two-person-verification-quality-improvement-initiative
     June 19, 2019 - July 10, 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.