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301. 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

302. 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

303. 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

304. 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

305. 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.

306. 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

307. 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

308. 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

309. 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.

310. 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

311. 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

312. 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

313. 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

314. 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

315. 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

316. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33579/psn-pdf
     September 15, 2024 - The modern field of systems analysis was pioneered by the British psychologist James Reason, whose analysis … These are discussed in more detail in the Root Cause Analysis Primer. … However, analysis of the incident also revealed many latent, or blunt end, causes. … (or the more generic term systems analysis) and prospective methods such as failure modes effect analysis … effectiveness-and-efficiency-root-cause-analysis-medicine cause analysis.

317. 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

318. 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

319. 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

320. 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