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321. 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

322. 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

323. 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

324. 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

325. 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

326. 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.

327. 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/

328. 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

329. 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

330. 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.

331. 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

332. 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

333. 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

334. 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.

335. 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

336. 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.

337. 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.

338. 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

339. 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.

340. 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