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  1. 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

  2. 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

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37872/psn-pdf
    January 11, 2017 - The effectiveness of root cause analysis: what does the literature tell us? … The effectiveness of root cause analysis: what does the literature tell us? … https://psnet.ahrq.gov/issue/effectiveness-root-cause-analysis-what-does-literature-tell-us This review … analyzes whether the available research on  root cause analysis (RCA) substantiates its effectiveness … /primer/root-cause-analysis https://psnet.ahrq.gov/issue/effectiveness-and-efficiency-root-cause-analysis-medicine

  4. 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.

  5. 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.

  6. 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.

  7. 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.

  8. Action needed to prevent dangerous heparin-insulin confusion. | PSNet

    psnet.ahrq.gov/issue/action-needed-prevent-dangerous-heparin-insulin-confusion
    May 07, 2018 - 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.

  9. Sterile water should not be given "freely." | PSNet

    psnet.ahrq.gov/issue/sterile-water-should-not-be-given-freely
    March 18, 2010 - 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.

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44773/psn-pdf
    January 13, 2016 - A tool for the concise analysis of patient safety incidents. … A Tool for the Concise Analysis of Patient Safety Incidents. … https://psnet.ahrq.gov/issue/tool-concise-analysis-patient-safety-incidents Once identified, adverse … investigation frameworks including the Canadian Incident Analysis Framework and the WHO High 5s program … https://psnet.ahrq.gov/issue/tool-concise-analysis-patient-safety-incidents https://psnet.ahrq.gov/primer

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45510/psn-pdf
    October 19, 2016 - How to perform a root cause analysis for workup and future prevention of medical errors: a review. … How to perform a root cause analysis for workup and future prevention of medical errors: a review. … https://psnet.ahrq.gov/issue/how-perform-root-cause-analysis-workup-and-future-prevention-medical- errors-review … Root cause analysis is a widely used strategy for understanding failure in patient care. … https://psnet.ahrq.gov/primer/root-cause-analysis https://psnet.ahrq.gov/primer/detection-safety-hazards

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39537/psn-pdf
    October 01, 2013 - Conducting root cause analysis with nursing students: best practice in nursing education. … Conducting root cause analysis with nursing students: best practice in nursing education. … https://psnet.ahrq.gov/issue/conducting-root-cause-analysis-nursing-students-best-practice-nursing- … education This commentary describes the use of root cause analysis to engage nursing students in identifying … https://psnet.ahrq.gov/primer/root-cause-analysis

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41297/psn-pdf
    September 19, 2012 - Failure mode and effects analysis: too little for too much? … Failure mode and effects analysis: too little for too much? … the benefits and drawbacks of using failure mode and effects analysis as a prospective risk assessment … https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-too-little-too-much https://psnet.ahrq.gov … /issue/failure-mode-and-effect-analysis-reliable https://psnet.ahrq.gov/issue/using-health-care-failure-mode-and-effect-analysis-va-national-center-patient-safetys

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38655/psn-pdf
    November 25, 2009 - Is failure mode and effect analysis reliable? November 25, 2009 Shebl NA, Franklin BD, Barber N. … Is failure mode and effect analysis reliable? … https://psnet.ahrq.gov/issue/failure-mode-and-effect-analysis-reliable Failure mode and effect analysis … (FMEA) is a widely used tool for hazard analysis. … https://psnet.ahrq.gov/issue/failure-mode-and-effect-analysis-reliable https://psnet.ahrq.gov/issue/using-health-care-failure-mode-and-effect-analysis-va-national-center-patient-safetys

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35479/psn-pdf
    June 14, 2011 - Implementing root cause analysis in an area health service: views of the participants. … Implementing root cause analysis in an area health service: views of the participants. … https://psnet.ahrq.gov/issue/implementing-root-cause-analysis-area-health-service-views-participants … https://psnet.ahrq.gov/issue/implementing-root-cause-analysis-area-health-service-views-participants … https://psnet.ahrq.gov/primer/root-cause-analysis https://psnet.ahrq.gov/primer/root-cause-analysis

  16. 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

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41941/psn-pdf
    February 11, 2013 - A cross-sectional study on the relationship between utilization of root cause analysis and patient safety … A cross-sectional study on the relationship between utilization of root cause analysis and patient safety … https://psnet.ahrq.gov/issue/cross-sectional-study-relationship-between-utilization-root-cause-analysis-and … - patient-safety Root cause analysis (RCA) has been a Joint Commission mandated tool for examining … https://psnet.ahrq.gov/primer/root-cause-analysis https://psnet.ahrq.gov/issue/sentinel-event https:

  18. 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.

  19. Developing a comprehensive framework of safeguarding strategies to address anticipated errors with organizational high-alert medications. | PSNet

    psnet.ahrq.gov/issue/developing-comprehensive-framework-safeguarding-strategies-address-anticipated-errors
    March 24, 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.

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40060/psn-pdf
    December 15, 2010 - Failure mode and effects analysis: an empirical comparison of failure mode scoring procedures. … Failure Mode and Effects Analysis. J Patient Saf. 2010;6(4):210-215. … https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-empirical-comparison-failure-mode-scoring … - procedures This study empirically demonstrated that different failure mode effect analysis (FMEA) … https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-empirical-comparison-failure-mode-scoring-procedures
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