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  1. 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
  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/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
  4. 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.
  5. 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
  6. psnet.ahrq.gov/issue/intravenous-admixture-preparation-considerations-parts-9-and-9-b-error-prevention-intravenous
    December 22, 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.
  7. 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.
  8. psnet.ahrq.gov/issue/lessons-denver-medication-errorcriminal-negligence-case-look-beyond-blaming-individuals
    June 16, 2019 - 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 9, 2010 ISMP medication error report analysis.
  9. 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
  10. 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
  11. 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
  12. psnet.ahrq.gov/issue/sentinel-event-alert-63-optimizing-smart-infusion-pump-safety-ders
    March 22, 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.
  13. psnet.ahrq.gov/issue/effect-multifaceted-clinical-pharmacist-intervention-medication-safety-after-hospitalization
    April 28, 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.
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837136/psn-pdf
    May 18, 2022 - What can we learn from in-depth analysis of human errors resulting in diagnostic errors in the emergency … department: an analysis of serious adverse event reports. … What can we learn from in-depth analysis of human errors resulting in diagnostic errors in the emergency … department: an analysis of serious adverse event reports. … https://psnet.ahrq.gov/issue/what-can-we-learn-depth-analysis-human-errors-resulting-diagnostic-errors
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849124/psn-pdf
    May 17, 2023 - Human factors and safety analysis methods used in the design and redesign of electronic medication … Human factors and safety analysis methods used in the design and redesign of electronic medication management … https://psnet.ahrq.gov/issue/human-factors-and-safety-analysis-methods-used-design-and-redesign- electronic-medication … Human factors and safety analysis methods can be used to increase the safety of new technologies, ideally … This review identifies human factors and safety analysis methods applied to EMMS.
  16. psnet.ahrq.gov/issue/listen-carefully-risk-error-spoken-medication-orders
    November 16, 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.
  17. psnet.ahrq.gov/issue/fda-updates-vinca-alkaloid-labeling-preparation-intravenous-infusion-bags-only
    February 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.
  18. psnet.ahrq.gov/issue/three-new-best-practices-2022-2023-targeted-medication-safety-best-practices-hospitals
    March 15, 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.
  19. psnet.ahrq.gov/issue/medication-safety-events-after-acute-myocardial-infarction-among-veterans-treated-va-versus
    April 07, 2022 - Department of Veterans Affairs: a qualitative 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/47096/psn-pdf
    November 14, 2018 - analysis system. … Analysis System. … - cause-analysis This analysis of the Veterans Health Administration root cause analysis database identified … https://psnet.ahrq.gov/issue/analysis-adverse-events-rehabilitation-department-using-veterans-affairs-root-cause-analysis … https://psnet.ahrq.gov/issue/analysis-adverse-events-rehabilitation-department-using-veterans-affairs-root-cause-analysis

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