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321. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60932/psn-pdf
     January 01, 2021 - Retrospective analysis of reported suicide deaths and attempts on Veterans Health Administration campuses … Retrospective analysis of reported suicide deaths and attempts on Veterans Health Administration campuses … https://psnet.ahrq.gov/issue/retrospective-analysis-reported-suicide-deaths-and-attempts-veterans-health … - administration This retrospective analysis used root cause analysis reports of suicide events in … https://psnet.ahrq.gov/issue/retrospective-analysis-reported-suicide-deaths-and-attempts-veterans-health-administration

322. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/851199/psn-pdf
     July 05, 2023 - Understanding the root cause analysis process to increase safety event reporting. … Understanding the root cause analysis process to increase safety event reporting. … https://psnet.ahrq.gov/issue/understanding-root-cause-analysis-process-increase-safety-event-reporting … Root cause analysis (RCA) may not be an ideal process, but it still creates opportunities for learning … https://psnet.ahrq.gov/primer/root-cause-analysis https://psnet.ahrq.gov/perspective/rethinking-root-cause-analysis

323. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/836812/psn-pdf
     March 30, 2022 - Tools covered in this primer include incident reporting systems, Root Cause Analysis (RCA), and Failure … Modes and Effects Analysis (FMEA). … Example Root Cause Analysis https://psnet.ahrq.gov/issue/wrong-site-and-wrong-patient-procedures-universal-protocol-era-analysis-prospective-database … Failure modes and effects analysis (FMEA) is a structured adverse event analysis tool that aims to … Root Cause Analysis: The Core of Problem Solving and Corrective Action, Second Edition.

324. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/837694/psn-pdf
     July 20, 2022 - Implementing root cause analysis and action: integrating human factors to create strong interventions … Implementing root cause analysis and action: integrating human factors to create strong interventions … https://psnet.ahrq.gov/issue/implementing-root-cause-analysis-and-action-integrating-human-factors- … This study found that integrating human factors into a new root cause analysis process led to an increase … https://psnet.ahrq.gov/issue/implementing-root-cause-analysis-and-action-integrating-human-factors-create-strong

325. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50938/psn-pdf
     February 26, 2020 - Risks and medication errors analysis to evaluate the impact of a chemotherapy compounding workflow … Risks and medication errors analysis to evaluate the impact of a chemotherapy compounding workflow management … https://psnet.ahrq.gov/issue/risks-and-medication-errors-analysis-evaluate-impact-chemotherapy- compounding-workflow … This study applied failure mode, effect, and criticality analysis (FMECA) methodology to identify the … https://psnet.ahrq.gov/issue/risks-and-medication-errors-analysis-evaluate-impact-chemotherapy-compounding-workflow

326. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60575/psn-pdf
     June 10, 2020 - Applying principles from aviation safety investigations to root cause analysis of a critical incident … Applying principles from aviation safety investigations to root cause analysis of a critical incident … https://psnet.ahrq.gov/issue/applying-principles-aviation-safety-investigations-root-cause-analysis-critical … - incident This case study describes the use of root cause analysis to investigate a critical incident … https://psnet.ahrq.gov/issue/applying-principles-aviation-safety-investigations-root-cause-analysis-critical-incident

327. Opioids, iatrogenic harm and disclosure of medical error. | PSNet
     psnet.ahrq.gov/issue/opioids-iatrogenic-harm-and-disclosure-medical-error
     November 21, 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.

328. Incidence of drug-related adverse events related to the use of high-alert drugs: a systematic review of randomized controlled trials. | PSNet
     psnet.ahrq.gov/issue/incidence-drug-related-adverse-events-related-use-high-alert-drugs-systematic-review
     May 20, 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.

329. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/837668/psn-pdf
     July 13, 2022 - Factors associated with malpractice claim payout: an analysis of closed emergency department claims. … Factors associated with malpractice claim payout: an analysis of closed emergency department claims. … https://psnet.ahrq.gov/issue/factors-associated-malpractice-claim-payout-analysis-closed-emergency- … department-claims Analysis of closed malpractice claims can be used to identify potential safety hazards … This analysis of closed emergency department malpractice claims indicates that diagnostic errors dominate

330. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/74084/psn-pdf
     November 17, 2021 - Healthcare failure mode and effect analysis in the chemotherapy preparation process. … Healthcare failure mode and effect analysis in the chemotherapy preparation process. … https://psnet.ahrq.gov/issue/healthcare-failure-mode-and-effect-analysis-chemotherapy-preparation- process … Researchers in this study used healthcare failure mode and effect analysis (HFMEA) to identify and … https://psnet.ahrq.gov/issue/healthcare-failure-mode-and-effect-analysis https://psnet.ahrq.gov/issue

331. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73485/psn-pdf
     July 14, 2021 - The RCA ReCAst: a root cause analysis simulation for the interprofessional clinical learning environment … The RCA ReCAst: a root cause analysis simulation for the interprofessional clinical learning environment … https://psnet.ahrq.gov/issue/rca-recast-root-cause-analysis-simulation-interprofessional-clinical-learning … - environment Root cause analysis (RCA) is a common method to investigate adverse events and identify … https://psnet.ahrq.gov/issue/rca-recast-root-cause-analysis-simulation-interprofessional-clinical-learning-environment

332. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73473/psn-pdf
     January 01, 2022 - Improving safety recommendations before implementation: a simulation-based event analysis to optimize … Improving safety recommendations before implementation: a simulation-based event analysis to optimize … https://psnet.ahrq.gov/issue/improving-safety-recommendations-implementation-simulation-based-event- analysis-optimize … Prior research has found that simulation-based event analysis (SBEA) can identify novel sources of … https://psnet.ahrq.gov/issue/improving-safety-recommendations-implementation-simulation-based-event-analysis-optimize

333. Examining causes and prevention strategies of adverse events in deceased hospital patients: a retrospective patient record review study in the Netherlands. | PSNet
     psnet.ahrq.gov/issue/examining-causes-and-prevention-strategies-adverse-events-deceased-hospital-patients
     June 08, 2022 - using the prevention and recovery information system for monitoring and analysis method in healthcare … April 7, 2021 Evolving factors in hospital safety: a systematic review and meta-analysis … October 6, 2021 A systematic review of methods for medical record analysis to detect … June 29, 2022 Hemodialysis bleeding events and deaths: an 18-year retrospective analysis … of patient safety and root cause analysis reports in the Veterans Health Administration.

334. Adverse drug events in hospitalized cardiac patients. | PSNet
     psnet.ahrq.gov/issue/adverse-drug-events-hospitalized-cardiac-patients
     July 26, 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.

335. ISMP survey on tall man (mixed case) lettering to reduce drug name confusion. | PSNet
     psnet.ahrq.gov/issue/ismp-survey-tall-man-mixed-case-lettering-reduce-drug-name-confusion
     January 26, 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.

336. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73258/psn-pdf
     May 12, 2021 - sepsis hospitalizations after misdiagnosis in adult emergency department patients: a look-forward analysis … with administrative claims data using Symptom-Disease Pair Analysis of Diagnostic Error methodology … sepsis hospitalizations after misdiagnosis in adult emergency department patients: a look-forward analysis … with administrative claims data using Symptom- Disease Pair Analysis of Diagnostic Error methodology … This study used a Symptom- Disease Pair Analysis of Diagnostic Error (SPADE) “look-forward” analysis

337. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/851651/psn-pdf
     July 26, 2023 - Using failure mode and effect analysis to identify potential failures in a psychiatric hospital emergency … Using failure mode and effect analysis to identify potential failures in a psychiatric hospital emergency … https://psnet.ahrq.gov/issue/using-failure-mode-and-effect-analysis-identify-potential-failures-psychiatric … - hospital Failure mode and effect analysis (FMEA) is a common way to identify error risk. … https://psnet.ahrq.gov/issue/using-failure-mode-and-effect-analysis-identify-potential-failures-psychiatric-hospital

338. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46646/psn-pdf
     January 01, 2021 - original methodological tool on the identification of corrective and preventive actions after root cause analysis … Original Methodological Tool on the Identification of Corrective and Preventive Actions After Root Cause Analysis … Investigators added a standardized tool to identify corrective and preventive actions to their root cause analysis … tool led to identification of more corrective and preventive actions than the preexisting root cause analysis … https://psnet.ahrq.gov/perspective/rethinking-root-cause-analysis

339. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/836824/psn-pdf
     March 30, 2022 - Collaborative case review: a systems-based approach to patient safety event investigation and analysis … Collaborative case review: a systems-based approach to patient safety event investigation and analysis … collaborative-case-review-systems-based-approach-patient-safety-event- investigation-and Root cause analysis … https://psnet.ahrq.gov/issue/sentinel-events-serious-reportable-events-and-root-cause-analysis https … ://psnet.ahrq.gov/issue/root-cause-analysis-health-care-joint-commission-guide-analysis-and-corrective-action

340. Development and performance evaluation of the Medicines Optimisation Assessment Tool (MOAT): a prognostic model to target hospital pharmacists' input to prevent medication-related problems. | PSNet
     psnet.ahrq.gov/issue/development-and-performance-evaluation-medicines-optimisation-assessment-tool-moat-prognostic
     March 18, 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.