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341. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43667/psn-pdf
     November 12, 2014 - Learning from preventable deaths: exploring case record reviewers' narratives using change analysis. … Learning from preventable deaths: exploring case record reviewers' narratives using change analysis. … Researchers applied change analysis, a type of root cause analysis, to their review of preventable … https://psnet.ahrq.gov/issue/investigation-and-analysis-critical-incidents-and-adverse-events-healthcare … https://psnet.ahrq.gov/primer/root-cause-analysis

342. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47230/psn-pdf
     August 15, 2018 - Experience feedback committees: a way of implementing a root cause analysis practice in hospital medical … Experience feedback committees: A way of implementing a root cause analysis practice in hospital medical … This study describes how a French hospital implemented a multidisciplinary root cause analysis infrastructure … An Annual Perspective discussed the limitations of root cause analysis and how this tool can be improved … https://psnet.ahrq.gov/primer/root-cause-analysis https://psnet.ahrq.gov/perspective/rethinking-root-cause-analysis

343. 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.

344. John M. Eisenberg Patient Safety Awards. Safety, effectiveness, and efficiency: a Web-based virtual anticoagulation clinic. | PSNet
     psnet.ahrq.gov/issue/john-m-eisenberg-patient-safety-awards-safety-effectiveness-and-efficiency-web-based-virtual
     September 13, 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.

345. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46346/psn-pdf
     October 29, 2017 - Root cause analysis of ICU adverse events in the Veterans Health Administration. … Root Cause Analysis of ICU Adverse Events in the Veterans Health Administration. … https://psnet.ahrq.gov/issue/root-cause-analysis-icu-adverse-events-veterans-health-administration Root … cause analysis is widely utilized in health care to examine adverse events. … /issue/veterans-affairs-root-cause-analysis-system-action

346. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45859/psn-pdf
     August 03, 2017 - Root cause analysis and actions for the prevention of medical errors: quality improvement and resident … Root Cause Analysis and Actions for the Prevention of Medical Errors: Quality Improvement and Resident … This commentary highlights the importance of engaging residents in root cause analysis of errors and … The authors discuss how participation in root cause analysis can educate trainees about process analysis … psnet.ahrq.gov/issue/patient-safety-orthopedic-surgery-prioritizing-key-areas-iatrogenic-harm-through-analysis

347. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44089/psn-pdf
     April 22, 2015 - Learning from mistakes and near mistakes: using root cause analysis as a risk management tool. … Learning From Mistakes and Near Mistakes: Using Root Cause Analysis as a Risk Management Tool. … https://psnet.ahrq.gov/issue/learning-mistakes-and-near-mistakes-using-root-cause-analysis-risk- management-tool … Root cause analysis has been promoted by The Joint Commission and other organizations as a failure … analysis tool, though problems with its usefulness remain due to issues with implementation and sufficient

348. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38352/psn-pdf
     June 14, 2011 - Developing a tool for assessing competency in root cause analysis. … Developing a tool for assessing competency in root cause analysis. … https://psnet.ahrq.gov/issue/developing-tool-assessing-competency-root-cause-analysis Root cause analysis … /primer/root-cause-analysis https://psnet.ahrq.gov/issue/veterans-affairs-root-cause-analysis-system-action … https://psnet.ahrq.gov/issue/effectiveness-and-efficiency-root-cause-analysis-medicine

349. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42446/psn-pdf
     May 19, 2014 - The Human Factors Analysis Classification System (HFACS) applied to health care. … The Human Factors Analysis Classification System (HFACS) applied to health care. … https://psnet.ahrq.gov/issue/human-factors-analysis-classification-system-hfacs-applied-health-care … This study reports on one health system's experience using the Human Factors Analysis Classification … ://psnet.ahrq.gov/primer/root-cause-analysis https://psnet.ahrq.gov/issue/effectiveness-and-efficiency-root-cause-analysis-medicine

350. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45225/psn-pdf
     June 15, 2016 - A case of transfusion error in a trauma patient with subsequent root cause analysis leading to institutional … A case of transfusion error in a trauma patient with subsequent root cause analysis leading to institutional … https://psnet.ahrq.gov/issue/case-transfusion-error-trauma-patient-subsequent-root-cause-analysis-leading … This case analysis discusses a wrong-patient transfusion error in a hospital's emergency room and reviews … findings of the subsequent root cause analysis, which determined training weaknesses, time pressures

351. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44098/psn-pdf
     April 29, 2015 - Evaluation of the suitability of root cause analysis frameworks for the investigation of community-acquired … pressure ulcers: a systematic review and documentary analysis. … Evaluation of the suitability of root cause analysis frameworks for the investigation of community-acquired … pressure ulcers: a systematic review and documentary analysis. … - acquired This systematic review discusses how root cause analysis methods can be used to understand

352. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34698/psn-pdf
     January 04, 2017 - Using Health Care Failure Mode and Effect Analysis: the VA National Center for Patient Safety's prospective … risk analysis system. … risk analysis system. … - safetys The authors describe their adaptation of failure mode and effects analysis, a prospective … Their system, Health Care Failure Mode Effects Analysis (HFMEA), is documented in detail, including

353. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/851656/psn-pdf
     July 26, 2023 - Investigation of urology intraoperative events leading to root cause analysis at national VA medical … https://psnet.ahrq.gov/issue/investigation-urology-intraoperative-events-leading-root-cause-analysis- … national-va-medical Root cause analysis (RCA) is one tool commonly used to identify factors contributing … https://psnet.ahrq.gov/issue/investigation-urology-intraoperative-events-leading-root-cause-analysis-national-va-medical … https://psnet.ahrq.gov/issue/investigation-urology-intraoperative-events-leading-root-cause-analysis-national-va-medical

354. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45710/psn-pdf
     December 22, 2017 - Our current approach to root cause analysis: is it contributing to our failure to improve patient safety … Our current approach to root cause analysis: is it contributing to our failure to improve patient safety … https://psnet.ahrq.gov/issue/our-current-approach-root-cause-analysis-it-contributing-our-failure-improve … - patient-safety Root cause analysis (RCA) is a process frequently employed by health care institutions … https://psnet.ahrq.gov/primer/root-cause-analysis https://psnet.ahrq.gov/issue/problem-root-cause-analysis

355. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40623/psn-pdf
     July 20, 2011 - Policy and practice in the use of root cause analysis to investigate clinical adverse events: mind the … Policy and practice in the use of root cause analysis to investigate clinical adverse events: mind the … https://psnet.ahrq.gov/issue/policy-and-practice-use-root-cause-analysis-investigate-clinical-adverse … - events-mind-gap This study explores the tensions between the theory of root cause analysis and its … https://psnet.ahrq.gov/primer/root-cause-analysis https://psnet.ahrq.gov/issue/effectiveness-and-efficiency-root-cause-analysis-medicine

356. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46777/psn-pdf
     January 24, 2018 - Safety analysis over time: seven major changes to adverse event investigation. … Safety analysis over time: seven major changes to adverse event investigation. … https://psnet.ahrq.gov/issue/safety-analysis-over-time-seven-major-changes-adverse-event-investigation … In-depth review and analysis of adverse events can both inform and detract from progress in patient … This commentary suggests that the early event analysis approaches have not achieved their potential.

357. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45298/psn-pdf
     April 22, 2017 - The problem with root cause analysis. April 22, 2017 Peerally MF, Carr S, Waring J, et al. … The problem with root cause analysis. … https://psnet.ahrq.gov/issue/problem-root-cause-analysis Root cause analysis (RCA) is a strategy to … this commentary suggests that challenges such as inappropriate focus on single-point causation, poor analysis … https://psnet.ahrq.gov/issue/problem-root-cause-analysis https://psnet.ahrq.gov/primer/root-cause-analysis

358. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44484/psn-pdf
     May 04, 2016 - Failure mode and effects analysis: a comparison of two common risk prioritisation methods. … Failure mode and effects analysis: a comparison of two common risk prioritisation methods. … https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-comparison-two-common-risk-prioritisation … - methods Failure mode and effect analysis (FMEA) is a human factors engineering method used to examine … Comparing a traditional resource-intensive FMEA with a simplified version, this analysis found that

359. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46152/psn-pdf
     May 31, 2017 - Root cause analysis of adverse events in an outpatient anticoagulation management consortium. … Root Cause Analysis of Adverse Events in an Outpatient Anticoagulation Management Consortium. … https://psnet.ahrq.gov/issue/root-cause-analysis-adverse-events-outpatient-anticoagulation-management … Unlike a prior study, researchers did not include patient perspectives in their analysis, which may … https://psnet.ahrq.gov/issue/root-cause-analysis-ambulatory-adverse-drug-events-present-emergency-department

360. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38303/psn-pdf
     December 17, 2008 - Errors and analysis of errors. December 17, 2008 Mulligan MA, Nechodom P. … Errors and analysis of errors. Clin Obstet Gynecol. 2008;51(4):656-65. … error reduction program and provides background on those strategies, including root cause analysis, … failure mode and effects analysis (FMEA), and human factors. … https://psnet.ahrq.gov/issue/errors-and-analysis-errors https://psnet.ahrq.gov/primer/root-cause-analysis