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401. 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

402. 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

403. 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

404. 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

405. 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.

406. Drug related admissions to a cardiology department; frequency and avoidability. | PSNet
     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.

407. 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

408. 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

409. 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

410. 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

411. 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

412. 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

413. ISMP's Guidelines for Standard Order Sets. | PSNet
     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.

414. Drug package inserts get mixed reception. | PSNet
     psnet.ahrq.gov/issue/drug-package-inserts-get-mixed-reception
     September 12, 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.

415. Medication errors and drug-dispensing systems in a hospital pharmacy. | PSNet
     psnet.ahrq.gov/issue/medication-errors-and-drug-dispensing-systems-hospital-pharmacy
     November 18, 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.

416. 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

417. 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

418. 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

419. 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

420. 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