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401. Strengthen your resolve: no unlabeled containers anywhere, ever! | PSNet
     psnet.ahrq.gov/issue/strengthen-your-resolve-no-unlabeled-containers-anywhere-ever
     November 16, 2015 - 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.

402. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40623/psn-pdf
     July 20, 2011 - Policy and practice in the use of root cause analysis to investigate clinical adverse events: mind the … Policy and practice in the use of root cause analysis to investigate clinical adverse events: mind the … https://psnet.ahrq.gov/issue/policy-and-practice-use-root-cause-analysis-investigate-clinical-adverse … - events-mind-gap This study explores the tensions between the theory of root cause analysis and its … https://psnet.ahrq.gov/primer/root-cause-analysis https://psnet.ahrq.gov/issue/effectiveness-and-efficiency-root-cause-analysis-medicine

403. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46777/psn-pdf
     January 24, 2018 - Safety analysis over time: seven major changes to adverse event investigation. … Safety analysis over time: seven major changes to adverse event investigation. … https://psnet.ahrq.gov/issue/safety-analysis-over-time-seven-major-changes-adverse-event-investigation … In-depth review and analysis of adverse events can both inform and detract from progress in patient … This commentary suggests that the early event analysis approaches have not achieved their potential.

404. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45298/psn-pdf
     April 22, 2017 - The problem with root cause analysis. April 22, 2017 Peerally MF, Carr S, Waring J, et al. … The problem with root cause analysis. … https://psnet.ahrq.gov/issue/problem-root-cause-analysis Root cause analysis (RCA) is a strategy to … this commentary suggests that challenges such as inappropriate focus on single-point causation, poor analysis … https://psnet.ahrq.gov/issue/problem-root-cause-analysis https://psnet.ahrq.gov/primer/root-cause-analysis

405. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46152/psn-pdf
     May 31, 2017 - Root cause analysis of adverse events in an outpatient anticoagulation management consortium. … Root Cause Analysis of Adverse Events in an Outpatient Anticoagulation Management Consortium. … https://psnet.ahrq.gov/issue/root-cause-analysis-adverse-events-outpatient-anticoagulation-management … Unlike a prior study, researchers did not include patient perspectives in their analysis, which may … https://psnet.ahrq.gov/issue/root-cause-analysis-ambulatory-adverse-drug-events-present-emergency-department

406. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44484/psn-pdf
     May 04, 2016 - Failure mode and effects analysis: a comparison of two common risk prioritisation methods. … Failure mode and effects analysis: a comparison of two common risk prioritisation methods. … https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-comparison-two-common-risk-prioritisation … - methods Failure mode and effect analysis (FMEA) is a human factors engineering method used to examine … Comparing a traditional resource-intensive FMEA with a simplified version, this analysis found that

407. Sterile water should not be given "freely." | PSNet
     psnet.ahrq.gov/issue/sterile-water-should-not-be-given-freely
     March 18, 2010 - 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.

408. Action needed to prevent dangerous heparin-insulin confusion. | PSNet
     psnet.ahrq.gov/issue/action-needed-prevent-dangerous-heparin-insulin-confusion
     May 07, 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.

409. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38303/psn-pdf
     December 17, 2008 - Errors and analysis of errors. December 17, 2008 Mulligan MA, Nechodom P. … Errors and analysis of errors. Clin Obstet Gynecol. 2008;51(4):656-65. … error reduction program and provides background on those strategies, including root cause analysis, … failure mode and effects analysis (FMEA), and human factors. … https://psnet.ahrq.gov/issue/errors-and-analysis-errors https://psnet.ahrq.gov/primer/root-cause-analysis

410. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45510/psn-pdf
     October 19, 2016 - How to perform a root cause analysis for workup and future prevention of medical errors: a review. … How to perform a root cause analysis for workup and future prevention of medical errors: a review. … https://psnet.ahrq.gov/issue/how-perform-root-cause-analysis-workup-and-future-prevention-medical- errors-review … Root cause analysis is a widely used strategy for understanding failure in patient care. … https://psnet.ahrq.gov/primer/root-cause-analysis https://psnet.ahrq.gov/primer/detection-safety-hazards

411. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44773/psn-pdf
     January 13, 2016 - A tool for the concise analysis of patient safety incidents. … A Tool for the Concise Analysis of Patient Safety Incidents. … https://psnet.ahrq.gov/issue/tool-concise-analysis-patient-safety-incidents Once identified, adverse … investigation frameworks including the Canadian Incident Analysis Framework and the WHO High 5s program … https://psnet.ahrq.gov/issue/tool-concise-analysis-patient-safety-incidents https://psnet.ahrq.gov/primer

412. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41941/psn-pdf
     February 11, 2013 - A cross-sectional study on the relationship between utilization of root cause analysis and patient safety … A cross-sectional study on the relationship between utilization of root cause analysis and patient safety … https://psnet.ahrq.gov/issue/cross-sectional-study-relationship-between-utilization-root-cause-analysis-and … - patient-safety Root cause analysis (RCA) has been a Joint Commission mandated tool for examining … https://psnet.ahrq.gov/primer/root-cause-analysis https://psnet.ahrq.gov/issue/sentinel-event https:

413. 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.

414. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37872/psn-pdf
     January 11, 2017 - The effectiveness of root cause analysis: what does the literature tell us? … The effectiveness of root cause analysis: what does the literature tell us? … https://psnet.ahrq.gov/issue/effectiveness-root-cause-analysis-what-does-literature-tell-us This review … analyzes whether the available research on root cause analysis (RCA) substantiates its effectiveness … /primer/root-cause-analysis https://psnet.ahrq.gov/issue/effectiveness-and-efficiency-root-cause-analysis-medicine

415. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39537/psn-pdf
     October 01, 2013 - Conducting root cause analysis with nursing students: best practice in nursing education. … Conducting root cause analysis with nursing students: best practice in nursing education. … https://psnet.ahrq.gov/issue/conducting-root-cause-analysis-nursing-students-best-practice-nursing- … education This commentary describes the use of root cause analysis to engage nursing students in identifying … https://psnet.ahrq.gov/primer/root-cause-analysis

416. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41297/psn-pdf
     September 19, 2012 - Failure mode and effects analysis: too little for too much? … Failure mode and effects analysis: too little for too much? … the benefits and drawbacks of using failure mode and effects analysis as a prospective risk assessment … https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-too-little-too-much https://psnet.ahrq.gov … /issue/failure-mode-and-effect-analysis-reliable https://psnet.ahrq.gov/issue/using-health-care-failure-mode-and-effect-analysis-va-national-center-patient-safetys

417. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38655/psn-pdf
     November 25, 2009 - Is failure mode and effect analysis reliable? November 25, 2009 Shebl NA, Franklin BD, Barber N. … Is failure mode and effect analysis reliable? … https://psnet.ahrq.gov/issue/failure-mode-and-effect-analysis-reliable Failure mode and effect analysis … (FMEA) is a widely used tool for hazard analysis. … https://psnet.ahrq.gov/issue/failure-mode-and-effect-analysis-reliable https://psnet.ahrq.gov/issue/using-health-care-failure-mode-and-effect-analysis-va-national-center-patient-safetys

418. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35479/psn-pdf
     June 14, 2011 - Implementing root cause analysis in an area health service: views of the participants. … Implementing root cause analysis in an area health service: views of the participants. … https://psnet.ahrq.gov/issue/implementing-root-cause-analysis-area-health-service-views-participants … https://psnet.ahrq.gov/issue/implementing-root-cause-analysis-area-health-service-views-participants … https://psnet.ahrq.gov/primer/root-cause-analysis https://psnet.ahrq.gov/primer/root-cause-analysis

419. 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.

420. 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.