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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40068/psn-pdf
    January 19, 2011 - Application of root cause analysis on malpractice claim files related to diagnostic failures. … Application of root cause analysis on malpractice claim files related to diagnostic failures. … https://psnet.ahrq.gov/issue/application-root-cause-analysis-malpractice-claim-files-related-diagnostic … - failures This study applied root cause analysis to cases of diagnostic failure, and discusses the … https://psnet.ahrq.gov/primer/root-cause-analysis https://psnet.ahrq.gov/primer/diagnostic-errors

  2. 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.

  3. 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

  4. 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

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44025/psn-pdf
    February 22, 2018 - The causes of their death appear (unto our shame perpetual): why root cause analysis is not the best … The Causes of Their Death Appear (Unto Our Shame Perpetual): Why Root Cause Analysis Is Not the Best … https://psnet.ahrq.gov/issue/causes-their-death-appear-unto-our-shame-perpetual-why-root-cause- analysis-not-best-model … Root cause analysis is a longstanding approach to in-depth investigation of adverse events, with evidence … method may not be helpful, their findings also emphasize the importance of implementing root cause analysis

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37562/psn-pdf
    June 14, 2011 - Effectiveness and efficiency of root cause analysis in medicine. June 14, 2011 Wu AW. … Effectiveness and Efficiency of Root Cause Analysis in Medicine. JAMA. 2008;299(6):685-687. … https://psnet.ahrq.gov/issue/effectiveness-and-efficiency-root-cause-analysis-medicine Application of … root cause analysis (RCA) continues to serve an important role in improving patient safety and quality … /primer/root-cause-analysis https://psnet.ahrq.gov/issue/veterans-affairs-root-cause-analysis-system-action

  7. 2009 National Patient Safety Goals. | PSNet

    psnet.ahrq.gov/issue/2009-national-patient-safety-goals
    August 03, 2016 - 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/41126/psn-pdf
    February 01, 2013 - The AMÉLIE project: failure mode, effects and criticality analysis: a model to evaluate the nurse medication … The AMÉLIE project: failure mode, effects and criticality analysis: a model to evaluate the nurse medication … https://psnet.ahrq.gov/issue/amelie-project-failure-mode-effects-and-criticality-analysis-model-evaluate … - nurse-medication This study reports on a multidisciplinary failure mode and effect analysis of nursing … https://psnet.ahrq.gov/issue/using-health-care-failure-mode-and-effect-analysis-va-national-center-patient-safetys

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38762/psn-pdf
    June 28, 2011 - Analysis of unintended events in hospitals: inter-rater reliability of constructing causal trees and … Analysis of unintended events in hospitals: inter-rater reliability of constructing causal trees and … https://psnet.ahrq.gov/issue/analysis-unintended-events-hospitals-inter-rater-reliability-constructing-causal … - trees-and Root cause analysis is commonly used to identify underlying system causes of adverse events … https://psnet.ahrq.gov/primer/root-cause-analysis

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42179/psn-pdf
    April 10, 2013 - Training health care professionals in root cause analysis: a cross-sectional study of post-training … Training health care professionals in root cause analysis: a cross-sectional study of post-training … https://psnet.ahrq.gov/issue/training-health-care-professionals-root-cause-analysis-cross-sectional-study … post-training According to this study, the majority of health care providers trained in root cause analysis … https://psnet.ahrq.gov/primer/root-cause-analysis

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39460/psn-pdf
    March 23, 2011 - Applying root cause analysis to improve patient safety: decreasing falls in postpartum women. … Applying root cause analysis to improve patient safety: decreasing falls in postpartum women. … https://psnet.ahrq.gov/issue/applying-root-cause-analysis-improve-patient-safety-decreasing-falls- postpartum-women … This Taiwanese study used root cause analysis to identify causal factors for falls in postpartum women … https://psnet.ahrq.gov/issue/applying-root-cause-analysis-improve-patient-safety-decreasing-falls-postpartum-women

  12. Development and performance evaluation of the Medicines Optimisation Assessment Tool (MOAT): a prognostic model to target hospital pharmacists' input to prevent medication-related problems. | PSNet

    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.

  13. Intravenous admixture preparation considerations, Parts 9-A and 9-B: error prevention in intravenous admixture preparation. | PSNet

    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.

  14. Lessons from the Denver medication error/criminal negligence case: look beyond blaming individuals. | PSNet

    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.

  15. Labeling morphine milligram equivalents on opioid packaging: a potential patient safety intervention. | PSNet

    psnet.ahrq.gov/issue/labeling-morphine-milligram-equivalents-opioid-packaging-potential-patient-safety
    March 06, 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 16, 2019 ISMP medication error report analysis.

  16. Sentinel Event Alert 63: optimizing smart infusion pump safety with DERS. | PSNet

    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.

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36689/psn-pdf
    June 14, 2011 - Root cause analysis. June 14, 2011 Stecker MS. Root cause analysis. … https://psnet.ahrq.gov/issue/root-cause-analysis The author provides an introduction to root cause analysis … https://psnet.ahrq.gov/issue/root-cause-analysis https://psnet.ahrq.gov/primer/root-cause-analysis

  18. 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

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40736/psn-pdf
    January 04, 2012 - Preventing wrong site, procedure, and patient events using a common cause analysis. … Preventing wrong site, procedure, and patient events using a common cause analysis. … https://psnet.ahrq.gov/issue/preventing-wrong-site-procedure-and-patient-events-using-common-cause- analysis … https://psnet.ahrq.gov/issue/preventing-wrong-site-procedure-and-patient-events-using-common-cause-analysis … https://psnet.ahrq.gov/primer/root-cause-analysis

  20. Medication errors related to product names. | PSNet

    psnet.ahrq.gov/issue/medication-errors-related-product-names
    January 02, 2017 - 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.
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