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  1. 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

  2. External Inquiry into the adverse incident that occurred at Queen's Medical Centre, Nottingham, 4th January 2001. | PSNet

    psnet.ahrq.gov/issue/external-inquiry-adverse-incident-occurred-queens-medical-centre-nottingham-4th-january-2001
    September 10, 2014 - 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.

  3. A crack in our best armor: "wrong patient" injections from insulin pens alarmingly frequent even with barcode scanning. | PSNet

    psnet.ahrq.gov/issue/crack-our-best-armor-wrong-patient-injections-insulin-pens-alarmingly-frequent-even-barcode
    October 22, 2014 - 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. … May 29, 2019 ISMP medication error report analysis.

  4. 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

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44967/psn-pdf
    March 16, 2016 - Wrong site surgery: a critical incident analysis of a near miss. March 16, 2016 Tichanow S. … Wrong site surgery: A critical incident analysis of a near miss. … https://psnet.ahrq.gov/issue/wrong-site-surgery-critical-incident-analysis-near-miss Despite efforts … https://psnet.ahrq.gov/issue/wrong-site-surgery-critical-incident-analysis-near-miss https://psnet.ahrq.gov … https://psnet.ahrq.gov/issue/using-near-misses-analysis-prevent-wrong-site-surgery https://psnet.ahrq.gov

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38727/psn-pdf
    November 25, 2009 - FMEA team performance in health care: a qualitative analysis of team member perceptions. … https://psnet.ahrq.gov/issue/fmea-team-performance-health-care-qualitative-analysis-team-member- perceptions … Failure mode and effect analysis (FMEA), a tool that allows prospective risk assessment, has been applied … https://psnet.ahrq.gov/issue/fmea-team-performance-health-care-qualitative-analysis-team-member-perceptions … https://psnet.ahrq.gov/issue/fmea-team-performance-health-care-qualitative-analysis-team-member-perceptions

  7. 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

  8. 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

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38207/psn-pdf
    January 15, 2009 - Analysis of medical emergency team calls comparing subjective to "objective" call criteria. … Analysis of medical emergency team calls comparing subjective to "objective" call criteria. … https://psnet.ahrq.gov/issue/analysis-medical-emergency-team-calls-comparing-subjective-objective-call … This analysis conducted at six Australian hospitals found that nurses' general concern about a patient … https://psnet.ahrq.gov/issue/analysis-medical-emergency-team-calls-comparing-subjective-objective-call-criteria

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42469/psn-pdf
    August 07, 2013 - Characteristics of paid malpractice claims settled in and out of court in the USA: a retrospective analysis … Characteristics of paid malpractice claims settled in and out of court in the USA: a retrospective analysis … psnet.ahrq.gov/issue/characteristics-paid-malpractice-claims-settled-and-out-court-usa- retrospective-analysis … This analysis of paid malpractice claims from the National Practitioner Data Bank found that the vast … psnet.ahrq.gov/issue/characteristics-paid-malpractice-claims-settled-and-out-court-usa-retrospective-analysis

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43501/psn-pdf
    September 10, 2014 - Emergency department patient safety incident characterization: an observational analysis of the findings … Emergency department patient safety incident characterization: an observational analysis of the findings … /psnet.ahrq.gov/issue/emergency-department-patient-safety-incident-characterization-observational- analysis-findings … Analysis of the data revealed that most emergency department patient safety incidents were primarily … ://psnet.ahrq.gov/issue/emergency-department-patient-safety-incident-characterization-observational-analysis-findings

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38735/psn-pdf
    June 24, 2009 - Reflection and analysis of how pharmacy students learn to communicate about medication errors. … Reflection and analysis of how pharmacy students learn to communicate about medication errors. … https://psnet.ahrq.gov/issue/reflection-and-analysis-how-pharmacy-students-learn-communicate-about- … https://psnet.ahrq.gov/issue/reflection-and-analysis-how-pharmacy-students-learn-communicate-about-medication-errors … https://psnet.ahrq.gov/issue/effectiveness-and-efficiency-root-cause-analysis-medicine https://psnet.ahrq.gov

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43777/psn-pdf
    January 01, 2015 - Smartphones let surgeons know WhatsApp: an analysis of communication in emergency surgical teams. … Smartphones let surgeons know WhatsApp: an analysis of communication in emergency surgical teams. … https://psnet.ahrq.gov/issue/smartphones-let-surgeons-know-whatsapp-analysis-communication- emergency-surgical-teams … Analysis of messages found it to be a safe and efficient method of communication that was perceived … https://psnet.ahrq.gov/issue/smartphones-let-surgeons-know-whatsapp-analysis-communication-emergency-surgical-teams

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43997/psn-pdf
    August 02, 2015 - Sentinel events, serious reportable events, and root cause analysis. … Sentinel events, serious reportable events, and root cause analysis. … https://psnet.ahrq.gov/issue/sentinel-events-serious-reportable-events-and-root-cause-analysis This … authors use ophthalmologic examples to illustrate the elements of a systematic approach to root cause analysis … https://psnet.ahrq.gov/issue/sentinel-events-serious-reportable-events-and-root-cause-analysis https:

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43565/psn-pdf
    March 22, 2016 - The role of failure mode and effects analysis in health care. March 22, 2016 Fibuch E, Ahmed A. … The role of failure mode and effects analysis in health care. Physician Exec. 2014;40(4):28-32. … https://psnet.ahrq.gov/issue/role-failure-mode-and-effects-analysis-health-care Failure mode and effects … analysis (FMEA) has been recommended as a method to detect safety hazards and proactively address system … https://psnet.ahrq.gov/issue/role-failure-mode-and-effects-analysis-health-care https://psnet.ahrq.gov

  16. 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

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41959/psn-pdf
    January 16, 2013 - Use of FMEA analysis to reduce risk of errors in prescribing and administering drugs in paediatric wards … Use of FMEA analysis to reduce risk of errors in prescribing and administering drugs in paediatric wards … https://psnet.ahrq.gov/issue/use-fmea-analysis-reduce-risk-errors-prescribing-and-administering-drugs … - paediatric-wards Failure mode and effect analysis identified calculation errors as a major source … https://psnet.ahrq.gov/issue/use-fmea-analysis-reduce-risk-errors-prescribing-and-administering-drugs-paediatric-wards

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43988/psn-pdf
    February 22, 2018 - rate of implementation of proposed actions for improvement with the Healthcare Failure Mode Effect Analysis … Rate of Implementation of Proposed Actions for Improvement With the Healthcare Failure Mode Effect Analysis … psnet.ahrq.gov/issue/high-rate-implementation-proposed-actions-improvement-healthcare-failure- mode-effect-analysis … Failure mode effect analysis is a widely used method of prospectively detecting safety hazards, but … psnet.ahrq.gov/issue/high-rate-implementation-proposed-actions-improvement-healthcare-failure-mode-effect-analysis

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44285/psn-pdf
    November 06, 2015 - Hospital board oversight of quality and safety: a stakeholder analysis exploring the role of trust and … Hospital board oversight of quality and safety: a stakeholder analysis exploring the role of trust and … https://psnet.ahrq.gov/issue/hospital-board-oversight-quality-and-safety-stakeholder-analysis-exploring … Trust among organizational leadership and prioritization of data analysis emerged as important methods … https://psnet.ahrq.gov/issue/hospital-board-oversight-quality-and-safety-stakeholder-analysis-exploring-role-trust-and

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43332/psn-pdf
    July 09, 2014 - Interventions to reduce the consequences of stress in physicians: a review and meta-analysis. … Interventions to reduce the consequences of stress in physicians: a review and meta-analysis. … https://psnet.ahrq.gov/issue/interventions-reduce-consequences-stress-physicians-review-and-meta- analysis … According to this meta-analysis, interventions that applied cognitive, behavioral, and mindfulness … https://psnet.ahrq.gov/issue/interventions-reduce-consequences-stress-physicians-review-and-meta-analysis
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