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  1. psnet.ahrq.gov/issue/drug-related-admissions-cardiology-department-frequency-and-avoidability
    August 20, 2018 - 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.
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38779/psn-pdf
    July 15, 2009 - Prospective risk analysis of health care processes: a systematic evaluation of the use of HFMEA in Dutch … Prospective risk analysis of health care processes: a systematic evaluation of the use of HFMEA in Dutch … https://psnet.ahrq.gov/issue/prospective-risk-analysis-health-care-processes-systematic-evaluation-use … - hfmea-dutch-health This study analyzed 13 failure mode and effect analysis (FMEA) efforts to understand … https://psnet.ahrq.gov/issue/prospective-risk-analysis-health-care-processes-systematic-evaluation-use-hfmea-dutch-health
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46075/psn-pdf
    May 03, 2017 - ED misdiagnosis of cerebrovascular events in the era of modern neuroimaging: a meta-analysis. … ED misdiagnosis of cerebrovascular events in the era of modern neuroimaging: A meta-analysis. … https://psnet.ahrq.gov/issue/ed-misdiagnosis-cerebrovascular-events-era-modern-neuroimaging-meta- analysis … This meta-analysis of diagnostic accuracy for cerebrovascular events in the emergency department found … https://psnet.ahrq.gov/issue/ed-misdiagnosis-cerebrovascular-events-era-modern-neuroimaging-meta-analysis
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35975/psn-pdf
    June 14, 2011 - A root cause analysis of clinical error: confronting the disjunction between formal rules and situated … A root cause analysis of clinical error: confronting the disjunction between formal rules and situated … https://psnet.ahrq.gov/issue/root-cause-analysis-clinical-error-confronting-disjunction-between-formal-rules … - and-situated The authors present the results of a root cause analysis (RCA) of an accidental morphine … https://psnet.ahrq.gov/primer/root-cause-analysis
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43006/psn-pdf
    April 02, 2014 - Hamilton Acute Pain Service Safety Study: using root cause analysis to reduce the incidence of adverse … Hamilton acute pain service safety study: using root cause analysis to reduce the incidence of adverse … https://psnet.ahrq.gov/issue/hamilton-acute-pain-service-safety-study-using-root-cause-analysis-reduce … - incidence-adverse The implementation of formal root cause analysis was associated with substantial … https://psnet.ahrq.gov/primer/root-cause-analysis
  6. 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.
  7. 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.
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836744/psn-pdf
    March 17, 2022 - Drug-related deaths among inpatients: a meta-analysis. … Drug-related deaths among inpatients: a meta-analysis. … https://psnet.ahrq.gov/issue/drug-related-deaths-among-inpatients-meta-analysis Adverse drug events … Based on 23 included studies from US and international settings, this meta-analysis estimated that drug-related … https://psnet.ahrq.gov/issue/drug-related-deaths-among-inpatients-meta-analysis https://psnet.ahrq.gov
  9. psnet.ahrq.gov/issue/improving-insulin-distribution-and-administration-safety-using-lean-six-sigma-methodologies
    March 19, 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.
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74212/psn-pdf
    January 01, 2022 - Using failure mode and effects analysis to increase patient safety in cancer chemotherapy. … Using Failure Mode and Effects Analysis to increase patient safety in cancer chemotherapy. … https://psnet.ahrq.gov/issue/using-failure-mode-and-effects-analysis-increase-patient-safety-cancer- … Using failure mode and effects analysis (FMEA), researchers identified potential failures related to … https://psnet.ahrq.gov/issue/using-failure-mode-and-effects-analysis-increase-patient-safety-cancer-chemotherapy
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/850167/psn-pdf
    June 07, 2023 - Perception of feeling safe perioperatively: a concept analysis. … Perception of feeling safe perioperatively: a concept analysis. … https://psnet.ahrq.gov/issue/perception-feeling-safe-perioperatively-concept-analysis Patients expect … This concept analysis describes defining attributes (participation, control, presence) of patients in … https://psnet.ahrq.gov/issue/perception-feeling-safe-perioperatively-concept-analysis https://psnet.ahrq.gov
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47290/psn-pdf
    December 12, 2018 - Burnout in mental health professionals: a systematic review and meta-analysis of prevalence and determinants … Burnout in mental health professionals: a systematic review and meta- analysis of prevalence and determinants … https://psnet.ahrq.gov/issue/burnout-mental-health-professionals-systematic-review-and-meta-analysis- … This systematic review and meta-analysis found high rates of burnout among mental health professionals … https://psnet.ahrq.gov/issue/burnout-mental-health-professionals-systematic-review-and-meta-analysis-prevalence-and
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849331/psn-pdf
    May 24, 2023 - Long-term care healthcare-associated infections in 2022: an analysis of 20,216 reports. … Long-term care healthcare-associated iInfections in 2022: an analysis of 20,216 reports. … https://psnet.ahrq.gov/issue/long-term-care-healthcare-associated-infections-2022-analysis-20216-reports … Based on incident data from the Pennsylvania Patient Safety Reporting System (PA-PSRS), this analysis … https://psnet.ahrq.gov/issue/long-term-care-healthcare-associated-infections-2022-analysis-20216-reports
  14. psnet.ahrq.gov/issue/ismps-guidelines-standard-order-sets
    May 11, 2017 - July 10, 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.
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35435/psn-pdf
    June 14, 2011 - Drill down with root cause analysis. June 14, 2011 McDonald A, Leyhane T. … Drill down with root cause analysis. Nurs Manage. 2005;36(10):26-32. … https://psnet.ahrq.gov/issue/drill-down-root-cause-analysis The authors outline a six-step process for … root cause analysis and highlight the importance of understanding state disclosure and discovery laws … https://psnet.ahrq.gov/issue/drill-down-root-cause-analysis https://psnet.ahrq.gov/primer/root-cause-analysis
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34803/psn-pdf
    January 05, 2017 - Systematic root cause analysis of adverse drug events in a tertiary referral hospital. … Systematic Root Cause Analysis of Adverse Drug Events in a Tertiary Referral Hospital. … This study examines the utility of root cause analysis (RCA) to identify, investigate, and address … The authors conclude that systematic application of root cause analysis, coupled with implementation … https://psnet.ahrq.gov/primer/root-cause-analysis https://psnet.ahrq.gov//#adversedrugevent
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45827/psn-pdf
    January 24, 2018 - Using failure mode and effects analysis to reduce patient safety risks related to the dispensing process … Using Failure mode and Effects Analysis to reduce patient safety risks related to the dispensing process … https://psnet.ahrq.gov/issue/using-failure-mode-and-effects-analysis-reduce-patient-safety-risks-related … - dispensing Failure mode and effect analysis is a tool commonly used to proactively assess the reliability … The authors describe the application of failure mode and effect analysis to identify failure modes in
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38861/psn-pdf
    August 26, 2009 - Survey evaluation of the National Patient Safety Agency’s Root Cause Analysis training programme in … Survey evaluation of the National Patient Safety Agency's Root Cause Analysis training programme in … https://psnet.ahrq.gov/issue/survey-evaluation-national-patient-safety-agencys-root-cause-analysis- … training-programme Formal root cause analysis (RCA) training conducted by the United Kingdom's National … https://psnet.ahrq.gov/primer/root-cause-analysis https://psnet.ahrq.gov/issue/national-patient-safety-agency-npsa
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35703/psn-pdf
    July 13, 2010 - Injury and liability associated with monitored anesthesia care: a closed claims analysis. … Injury and liability associated with monitored anesthesia care: a closed claims analysis. … https://psnet.ahrq.gov/issue/injury-and-liability-associated-monitored-anesthesia-care-closed-claims- analysis … Investigators performed a detailed analysis of more than 120 MAC claims, compared them with those of … https://psnet.ahrq.gov/issue/adverse-respiratory-events-anesthesia-closed-claims-analysis
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38697/psn-pdf
    June 10, 2009 - A report card system using error profile analysis and concurrent morbidity and mortality review: surgical … outcome analysis, part II. … A report card system using error profile analysis and concurrent morbidity and mortality review: surgical … outcome analysis, part II. … https://psnet.ahrq.gov/issue/report-card-system-using-error-profile-analysis-and-concurrent-morbidity-and

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