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3921. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37086/psn-pdf
      October 03, 2011 - Failure mode and effects analysis: a useful tool for risk identification and injury prevention. … Failure mode and effects analysis: a useful tool for risk identification and injury prevention. … https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-useful-tool-risk-identification-and-injury … proactive risk assessment and provides insights on the successful use of failure mode and effects analysis … https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-useful-tool-risk-identification-and-injury-prevention

3922. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38343/psn-pdf
      December 09, 2014 - Liability associated with obstetric anesthesia: a closed claims analysis. … Liability associated with obstetric anesthesia: a closed claims analysis. … https://psnet.ahrq.gov/issue/liability-associated-obstetric-anesthesia-closed-claims-analysis The use … https://psnet.ahrq.gov/issue/liability-associated-obstetric-anesthesia-closed-claims-analysis https:/ … https://psnet.ahrq.gov/issue/adverse-respiratory-events-anesthesia-closed-claims-analysis

3923. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41858/psn-pdf
      November 21, 2012 - Disorganized care: the findings of an iterative, in-depth analysis of surgical morbidity and mortality … Disorganized care: the findings of an iterative, in-depth analysis of surgical morbidity and mortality … https://psnet.ahrq.gov/issue/disorganized-care-findings-iterative-depth-analysis-surgical-morbidity-and … conferences over a 3-year period at one academic hospital and used insights from a modified root cause analysis … https://psnet.ahrq.gov/primer/systems-approach https://psnet.ahrq.gov/primer/root-cause-analysis https

3924. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38753/psn-pdf
      July 01, 2009 - Evaluation of safety in a radiation oncology setting using failure mode and effects analysis. … Evaluation of safety in a radiation oncology setting using failure mode and effects analysis. … /psnet.ahrq.gov/issue/evaluation-safety-radiation-oncology-setting-using-failure-mode-and-effects- analysis … Failure mode and effects analysis was used to prospectively analyze an external beam radiation therapy … ://psnet.ahrq.gov/issue/evaluation-safety-radiation-oncology-setting-using-failure-mode-and-effects-analysis

3925. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36331/psn-pdf
      October 26, 2010 - Using system analysis to build a safety culture: improving the reliability of epidural analgesia. … Using system analysis to build a safety culture: improving the reliability of epidural analgesia. … https://psnet.ahrq.gov/issue/using-system-analysis-build-safety-culture-improving-reliability-epidural … - analgesia The authors describe the systematic analysis of an incident involving inappropriate use … https://psnet.ahrq.gov/issue/using-system-analysis-build-safety-culture-improving-reliability-epidural-analgesia

3926. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41554/psn-pdf
      January 03, 2017 - Using root cause analysis to reduce falls with injury in community settings. … Using root cause analysis to reduce falls with injury in community settings. … https://psnet.ahrq.gov/issue/using-root-cause-analysis-reduce-falls-injury-community-settings This study … used root cause analysis (RCA) to identify hazards leading to falls among community-dwelling elderly … /psnet.ahrq.gov/primer/root-cause-analysis https://psnet.ahrq.gov/primer/ambulatory-care-safety

3927. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40218/psn-pdf
      December 29, 2014 - Preventable adverse drug events and their causes and contributing factors: the analysis of register … Preventable adverse drug events and their causes and contributing factors: the analysis of register … ://psnet.ahrq.gov/issue/preventable-adverse-drug-events-and-their-causes-and-contributing-factors- analysis-register … https://psnet.ahrq.gov/issue/preventable-adverse-drug-events-and-their-causes-and-contributing-factors-analysis-register … https://psnet.ahrq.gov/issue/preventable-adverse-drug-events-and-their-causes-and-contributing-factors-analysis-register

3928. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42670/psn-pdf
      January 09, 2014 - Meta-analysis of surgical safety checklist effects on teamwork, communication, morbidity, mortality, … Meta-analysis of surgical safety checklist effects on teamwork, communication, morbidity, mortality, … https://psnet.ahrq.gov/issue/meta-analysis-surgical-safety-checklist-effects-teamwork-communication- … morbidity-mortality This meta-analysis of 19 surgical checklist studies found that checklists improved … https://psnet.ahrq.gov/issue/meta-analysis-surgical-safety-checklist-effects-teamwork-communication-morbidity-mortality

3929. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37132/psn-pdf
      June 14, 2011 - Preventing medication errors in community pharmacy: root-cause analysis of transcription errors. … Preventing medication errors in community pharmacy: root- cause analysis of transcription errors. … https://psnet.ahrq.gov/issue/preventing-medication-errors-community-pharmacy-root-cause-analysis- transcription-errors … https://psnet.ahrq.gov/issue/preventing-medication-errors-community-pharmacy-root-cause-analysis-transcription-errors … https://psnet.ahrq.gov/primer/root-cause-analysis https://psnet.ahrq.gov//#adversedrugevent

3930. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44339/psn-pdf
      July 29, 2015 - Rapid response systems: a systematic review and meta- analysis. … Rapid response systems: a systematic review and meta-analysis. … https://psnet.ahrq.gov/issue/rapid-response-systems-systematic-review-and-meta-analysis This meta-analysis … This analysis supports the current widespread implementation of rapid response. … https://psnet.ahrq.gov/issue/rapid-response-systems-systematic-review-and-meta-analysis https://psnet.ahrq.gov

3931. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40729/psn-pdf
      October 04, 2011 - Critical incident reports concerning anaesthetic equipment: analysis of the UK National Reporting and … Critical incident reports concerning anaesthetic equipment: analysis of the UK National Reporting and … https://psnet.ahrq.gov/issue/critical-incident-reports-concerning-anaesthetic-equipment-analysis-uk- … national-reporting-and Analysis of critical incidents involving anesthesia equipment failure found … https://psnet.ahrq.gov/issue/critical-incident-reports-concerning-anaesthetic-equipment-analysis-uk-national-reporting-and

3932. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36207/psn-pdf
      October 13, 2010 - Using failure mode and effects analysis to plan implementation of smart i.v. pump technology. … Using failure mode and effects analysis to plan implementation of smart i.v. pump technology. … https://psnet.ahrq.gov/issue/using-failure-mode-and-effects-analysis-plan-implementation-smart-iv-pump … - technology The authors describe their use of failure mode and effects analysis to inform the launch … https://psnet.ahrq.gov/issue/using-failure-mode-and-effects-analysis-plan-implementation-smart-iv-pump-technology

3933. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43335/psn-pdf
      July 09, 2014 - Wake Up Safe and root cause analysis: quality improvement in pediatric anesthesia. … Wake Up Safe and root cause analysis: quality improvement in pediatric anesthesia. … https://psnet.ahrq.gov/issue/wake-safe-and-root-cause-analysis-quality-improvement-pediatric-anesthesia … This commentary provides an overview of root cause analysis methods and describes an initiative that … https://psnet.ahrq.gov/issue/wake-safe-and-root-cause-analysis-quality-improvement-pediatric-anesthesia

3934. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37861/psn-pdf
      June 25, 2008 - Adverse outcomes of blood transfusion in children: analysis of UK reports to the serious hazards of … Adverse outcomes of blood transfusion in children: analysis of UK reports to the serious hazards of … https://psnet.ahrq.gov/issue/adverse-outcomes-blood-transfusion-children-analysis-uk-reports-serious- … hazards-transfusion This analysis of data from a voluntary reporting system in Britain provides an … https://psnet.ahrq.gov/issue/adverse-outcomes-blood-transfusion-children-analysis-uk-reports-serious-hazards-transfusion

3935. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37275/psn-pdf
      December 23, 2011 - Developing indicators of inpatient adverse drug events through nonlinear analysis using administrative … Developing indicators of inpatient adverse drug events through nonlinear analysis using administrative … https://psnet.ahrq.gov/issue/developing-indicators-inpatient-adverse-drug-events-through-nonlinear- analysis-using … This study demonstrated the value of hierarchically optimal classification tree analysis as a promising … https://psnet.ahrq.gov/issue/developing-indicators-inpatient-adverse-drug-events-through-nonlinear-analysis-using

3936. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43022/psn-pdf
      May 29, 2014 - Using simulation to improve root cause analysis of adverse surgical outcomes. … Using simulation to improve root cause analysis of adverse surgical outcomes. … https://psnet.ahrq.gov/issue/using-simulation-improve-root-cause-analysis-adverse-surgical-outcomes … Comparing the use of case simulation with root cause analysis for investigating adverse surgical outcomes … ://psnet.ahrq.gov/primer/simulation-training https://psnet.ahrq.gov/primer/root-cause-analysis https:

3937. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42679/psn-pdf
      October 23, 2013 - An evidence-based toolkit for the development of effective and sustainable root cause analysis system … An evidence-based toolkit for the development of effective and sustainable root cause analysis system … https://psnet.ahrq.gov/issue/evidence-based-toolkit-development-effective-and-sustainable-root-cause- analysis-system … https://psnet.ahrq.gov/issue/evidence-based-toolkit-development-effective-and-sustainable-root-cause-analysis-system … https://psnet.ahrq.gov/primer/root-cause-analysis https://psnet.ahrq.gov/primer/systems-approach

3938. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45666/psn-pdf
      April 24, 2018 - The relationship between professional burnout and quality and safety in healthcare: a meta-analysis. … The Relationship Between Professional Burnout and Quality and Safety in Healthcare: A Meta-Analysis. … psnet.ahrq.gov/issue/relationship-between-professional-burnout-and-quality-and-safety-healthcare- meta-analysis … This meta-analysis examined the relationship of burnout to health care quality. … In the pooled analysis, higher levels of burnout were associated with lower reported quality and safety

3939. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39735/psn-pdf
      January 03, 2017 - A practical guide to Failure Mode and Effects Analysis in health care: making the most of the team and … A practical guide to Failure Mode and Effects Analysis in health care: making the most of the team and … https://psnet.ahrq.gov/issue/practical-guide-failure-mode-and-effects-analysis-health-care-making-most … team-and-its This commentary describes one hospital's experience implementing Failure Mode and Effects Analysis … https://psnet.ahrq.gov/issue/practical-guide-failure-mode-and-effects-analysis-health-care-making-most-team-and-its

3940. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42329/psn-pdf
      December 18, 2014 - Health care failure mode and effect analysis to reduce NICU line–associated bloodstream infections. … Health care failure mode and effect analysis to reduce NICU line-associated bloodstream infections. … https://psnet.ahrq.gov/issue/health-care-failure-mode-and-effect-analysis-reduce-nicu-line-associated … - bloodstream Successful application of a failure mode and effect analysis approach resulted in a marked … https://psnet.ahrq.gov/issue/health-care-failure-mode-and-effect-analysis-reduce-nicu-line-associated-bloodstream