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361. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39303/psn-pdf
     February 17, 2010 - Patient misidentification in laboratory medicine: a qualitative analysis of 227 root cause analysis … Patient misidentification in laboratory medicine: a qualitative analysis of 227 root cause analysis … https://psnet.ahrq.gov/issue/patient-misidentification-laboratory-medicine-qualitative-analysis-227-root … https://psnet.ahrq.gov/issue/patient-misidentification-laboratory-medicine-qualitative-analysis-227-root-cause-analysis … root-cause-analysis https://psnet.ahrq.gov/primer/root-cause-analysis

362. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43281/psn-pdf
     May 28, 2015 - A method for prioritizing interventions following root cause analysis (RCA): lessons from philosophy … A method for prioritizing interventions following root cause analysis (RCA): lessons from philosophy … https://psnet.ahrq.gov/issue/method-prioritizing-interventions-following-root-cause-analysis-rca-lessons … This commentary suggests a three-step approach for optimizing root cause analysis results to detect … https://psnet.ahrq.gov/primer/root-cause-analysis https://psnet.ahrq.gov/issue/effectiveness-and-efficiency-root-cause-analysis-medicine

363. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45967/psn-pdf
     July 05, 2017 - Root-cause analysis: swatting at mosquitoes versus draining the swamp. … Root-cause analysis: swatting at mosquitoes versus draining the swamp. … https://psnet.ahrq.gov/issue/root-cause-analysis-swatting-mosquitoes-versus-draining-swamp Although … A recent Annual Perspective discussed ongoing problems with the root cause analysis process and described … /issue/our-current-approach-root-cause-analysis-it-contributing-our-failure-improve-patient-safety https

364. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41022/psn-pdf
     December 21, 2011 - Key performance outcomes of patient safety curricula: root cause analysis, failure mode and effects … analysis, and structured communications skills. … Key performance outcomes of patient safety curricula: root cause analysis, failure mode and effects … analysis, and structured communications skills. … https://psnet.ahrq.gov/primer/root-cause-analysis

365. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39542/psn-pdf
     May 19, 2010 - Random safety auditing, root cause analysis, failure mode and effects analysis. … Random Safety Auditing, Root Cause Analysis, Failure Mode and Effects Analysis. … https://psnet.ahrq.gov/issue/random-safety-auditing-root-cause-analysis-failure-mode-and-effects-analysis … This essay introduces three primary analysis techniques from industry that demonstrate effectiveness … https://psnet.ahrq.gov/issue/random-safety-auditing-root-cause-analysis-failure-mode-and-effects-analysis

366. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47075/psn-pdf
     November 21, 2018 - Integrating systemic accident analysis into patient safety incident investigation practices. … Integrating systemic accident analysis into patient safety incident investigation practices. … https://psnet.ahrq.gov/issue/integrating-systemic-accident-analysis-patient-safety-incident-investigation … Systems Theoretic Accident Modelling and Processes (STAMP) analysis—for the same adverse event. … https://psnet.ahrq.gov/primer/root-cause-analysis https://psnet.ahrq.gov/primer/systems-approach

367. 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

368. 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

369. 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

370. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47508/psn-pdf
     October 24, 2018 - Root cause analysis of reported patient falls in ORs in the Veterans Health Administration. … Root Cause Analysis of Reported Patient Falls in ORs in the Veterans Health Administration. … https://psnet.ahrq.gov/issue/root-cause-analysis-reported-patient-falls-ors-veterans-health-administration … Root cause analysis has been widely promoted as a failure analysis tool for use in a variety of settings … https://psnet.ahrq.gov/perspective/rethinking-root-cause-analysis

371. 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

372. 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

373. 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

374. 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

375. 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

376. 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

377. 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

378. 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

379. 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

380. 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