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  1. 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.

  2. 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.

  3. 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

  4. 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.

  5. 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.

  6. 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.

  7. 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.

  8. 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

  9. 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-

  10. 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.

  11. 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.

  12. 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

  13. 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

  14. 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.

  15. 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

  16. 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

  17. 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

  18. 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.

  19. 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.

  20. 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
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