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41. Experience feedback committees: a way of implementing a root cause analysis practice in hospital medical departments. | PSNet
    psnet.ahrq.gov/issue/experience-feedback-committees-way-implementing-root-cause-analysis-practice-hospital-medical
    October 30, 2024 - Study Experience feedback committees: a way of implementing a root cause analysis … Experience feedback committees: A way of implementing a root cause analysis practice in hospital medical … An Annual Perspective discussed the limitations of root cause analysis and how this tool can be improved … Experience feedback committees: A way of implementing a root cause analysis practice in hospital medical … November 1, 2017 Root-cause analysis: swatting at mosquitoes versus draining the swamp

42. Patient misidentification in laboratory medicine: a qualitative analysis of 227 root cause analysis reports in the Veterans Health Administration. | PSNet
    psnet.ahrq.gov/issue/patient-misidentification-laboratory-medicine-qualitative-analysis-227-root-cause-analysis
    August 28, 2024 - Study Patient misidentification in laboratory medicine: a qualitative analysis of … 227 root cause analysis reports in the Veterans Health Administration. … Patient misidentification in laboratory medicine: a qualitative analysis of 227 root cause analysis reports … Patient misidentification in laboratory medicine: a qualitative analysis of 227 root cause analysis reports … April 30, 2014 Root cause analysis reports help identify common factors in delayed diagnosis

43. Root cause analysis for hospital-acquired pressure injury. | PSNet
    psnet.ahrq.gov/issue/root-cause-analysis-hospital-acquired-pressure-injury
    July 07, 2021 - Review Root cause analysis for hospital-acquired pressure injury. … Root cause analysis for hospital-acquired pressure injury. … The author suggests that common cause analysis is an effective method to utilize root cause analysis … Root cause analysis for hospital-acquired pressure injury. … program using root cause analysis and common cause analysis.

44. The weekend effect in hospitalized patients: a meta-analysis. | PSNet
    psnet.ahrq.gov/issue/weekend-effect-hospitalized-patients-meta-analysis
    September 23, 2020 - Review The weekend effect in hospitalized patients: a meta-analysis. … The Weekend Effect in Hospitalized Patients: A Meta-Analysis. … This meta-analysis of 97 studies found that all-cause mortality is higher for patients hospitalized on … The Weekend Effect in Hospitalized Patients: A Meta-Analysis.

45. Human error and the problem of causality in analysis of accidents. | PSNet
    psnet.ahrq.gov/issue/human-error-and-problem-causality-analysis-accidents
    August 25, 2021 - Commentary Classic Human error and the problem of causality in analysis … Human error and the problem of causality in analysis of accidents. … Discussion includes the causal analysis of accidents, human error and behavior, human and system adaptation … Human error and the problem of causality in analysis of accidents. … , 2005 View More See More About The Topic Safety Scientists Error Analysis

46. Using Health Care Failure Mode and Effect Analysis: the VA National Center for Patient Safety's prospective risk analysis system. | PSNet
    psnet.ahrq.gov/issue/using-health-care-failure-mode-and-effect-analysis-va-national-center-patient-safetys
    January 17, 2012 - : the VA National Center for Patient Safety's prospective risk analysis system. … risk analysis system. … risk analysis system. … August 15, 2012 Healthcare Failure Mode and Effect Analysis. … analysis in a pediatric oncology ward.

47. Key performance outcomes of patient safety curricula: root cause analysis, failure mode and effects analysis, and structured communications skills. | PSNet
    psnet.ahrq.gov/issue/key-performance-outcomes-patient-safety-curricula-root-cause-analysis-failure-mode-and
    July 23, 2010 - , failure mode and effects analysis, and structured communications skills. … Key performance outcomes of patient safety curricula: root cause analysis, failure mode and effects analysis … This commentary recommends that courses covering root cause analysis , failure mode and effects analysis … Key performance outcomes of patient safety curricula: root cause analysis, failure mode and effects analysis … Failure Mode Effects Analysis View More

48. Complications in surgery: root cause analysis and preventive measures. | PSNet
    psnet.ahrq.gov/issue/complications-surgery-root-cause-analysis-and-preventive-measures
    November 24, 2021 - Commentary Complications in surgery: root cause analysis and preventive measures. … Complications in surgery: root cause analysis and preventive measures. … Complications in surgery: root cause analysis and preventive measures. … care program using root cause analysis and common cause analysis. … July 20, 2022 Assisting beginners in root cause analysis operations: analysis and recommendations

49. Drug-related deaths among inpatients: a meta-analysis. | PSNet
    psnet.ahrq.gov/issue/drug-related-deaths-among-inpatients-meta-analysis
    May 25, 2022 - Study Drug-related deaths among inpatients: a meta-analysis. … Drug-related deaths among inpatients: a meta-analysis. … Based on 23 included studies from US and international settings, this meta-analysis estimated that drug-related … Drug-related deaths among inpatients: a meta-analysis. … A systematic review and meta-analysis.

50. Use of dimensional analysis to reduce medication errors. | PSNet
    psnet.ahrq.gov/issue/use-dimensional-analysis-reduce-medication-errors
    August 06, 2014 - Study Use of dimensional analysis to reduce medication errors. … Citation Text: Use of dimensional analysis to reduce medication errors. … students on medication dosage calculation and found that those students who were taught using dimensional analysis … URL Cite Citation Citation Text: Use of dimensional analysis

51. Systems Analysis of Critical Incidents: the London Protocol. | PSNet
    psnet.ahrq.gov/issue/systems-analysis-critical-incidents-london-protocol
    April 06, 2016 - Book/Report Systems Analysis of Critical Incidents: the London Protocol. … Citation Text: Systems Analysis of Critical Incidents: the London Protocol. … This revised report documents a process for adverse event analysis that risk managers and others may … Copy URL Cite Citation Citation Text: Systems Analysis … May 24, 2015 Systematic Systems Analysis: A Practical Approach to Patient Safety Reviews

52. What are the experiences of team members involved in root cause analysis? A qualitative study. | PSNet
    psnet.ahrq.gov/issue/what-are-experiences-team-members-involved-root-cause-analysis-qualitative-study
    August 16, 2023 - Study What are the experiences of team members involved in root cause analysis? … What are the experiences of team members involved in root cause analysis? A qualitative study. … What are the experiences of team members involved in root cause analysis? A qualitative study. … A content analysis of accreditation reports. … root cause analysis investigations.

53. Failure mode and effects analysis outputs: are they valid? | PSNet
    psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-outputs-are-they-valid
    November 25, 2009 - Study Failure mode and effects analysis outputs: are they valid? … Failure mode and effects analysis outputs: are they valid? … Failure mode and effects analysis outputs: are they valid? … : the VA National Center for Patient Safety's prospective risk analysis system. … June 12, 2013 Health Care Failure Mode and Effect Analysis: a useful proactive risk analysis

54. Medical Device Use Error: Root Cause Analysis. | PSNet
    psnet.ahrq.gov/issue/medical-device-use-error-root-cause-analysis
    January 10, 2018 - Book/Report Medical Device Use Error: Root Cause Analysis. … Citation Text: Medical Device Use Error: Root Cause Analysis. Wiklund M, Dwyer A, Davis E. … Cite Citation Citation Text: Medical Device Use Error: Root Cause Analysis … May 17, 2023 More than algorithms: an analysis of safety events involving ML-enabled … May 3, 2023 Using the Generic Analysis Method to analyze sentinel event reports across

55. Radiology failure mode and effect analysis: what is it? | PSNet
    psnet.ahrq.gov/issue/radiology-failure-mode-and-effect-analysis-what-it
    May 03, 2017 - Commentary Radiology failure mode and effect analysis: what is it? … Radiology failure mode and effect analysis: what is it? … This article introduces the concept of failure mode and effect analysis , outlines the process, and … Radiology failure mode and effect analysis: what is it? … analysis.

56. Root Cause Analysis Gone Wrong | PSNet
    psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong
    August 28, 2024 - Root Cause Analysis Gone Wrong Citation Text: Peerally MF, Dixon-Woods M. … Root Cause Analysis Gone Wrong. PSNet [internet]. … Root Cause Analysis Gone Wrong. PSNet [internet]. … Newer paradigms of accident causation and analysis draw on systems theory. … Root Cause Analysis Gone Wrong. PSNet [internet].

57. A tool for the concise analysis of patient safety incidents. | PSNet
    psnet.ahrq.gov/issue/tool-concise-analysis-patient-safety-incidents
    August 09, 2018 - Study A tool for the concise analysis of patient safety incidents. … A Tool for the Concise Analysis of Patient Safety Incidents. … In this study, researchers tested a concise incident analysis method, drawing on multiple existing incident … investigation frameworks including the Canadian Incident Analysis Framework and the WHO High 5s program … A Tool for the Concise Analysis of Patient Safety Incidents.

58. Analysis of paediatric long-term ventilation incidents in the community | PSNet
    psnet.ahrq.gov/issue/analysis-paediatric-long-term-ventilation-incidents-community
    November 06, 2024 - Study Analysis of paediatric long-term ventilation incidents in the community … Analysis of paediatric long-term ventilation incidents in the community. … This analysis of 220 national incident data from England and Wales’ National Reporting and Learning … Analysis of paediatric long-term ventilation incidents in the community. … February 17, 2016 Developing person-centred analysis of harm in a paediatric hospital

59. Integrating systemic accident analysis into patient safety incident investigation practices. | PSNet
    psnet.ahrq.gov/issue/integrating-systemic-accident-analysis-patient-safety-incident-investigation-practices
    October 27, 2021 - Study Integrating systemic accident analysis into patient safety incident investigation … Integrating systemic accident analysis into patient safety incident investigation practices. … Theoretic Accident Modelling and Processes (STAMP) analysis—for the same adverse event. … A qualitative study combining human factors/ergonomics and social science analysis. … January 29, 2020 The problem with root cause analysis.

60. A root cause analysis project in a medication safety course. | PSNet
    psnet.ahrq.gov/issue/root-cause-analysis-project-medication-safety-course
    October 07, 2020 - Commentary A root cause analysis project in a medication safety course. … A root cause analysis project in a medication safety course. … This commentary describes an initiative to integrate development of root cause analysis skills into … A root cause analysis project in a medication safety course. … , failure mode and effects analysis, and structured communications skills.