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421. 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.

422. 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.

423. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41508/psn-pdf
     July 11, 2012 - Complications in surgery: root cause analysis and preventive measures. … Complications in surgery: root cause analysis and preventive measures. … https://psnet.ahrq.gov/issue/complications-surgery-root-cause-analysis-and-preventive-measures This … https://psnet.ahrq.gov/issue/complications-surgery-root-cause-analysis-and-preventive-measures https: … //psnet.ahrq.gov/primer/root-cause-analysis

424. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40898/psn-pdf
     February 06, 2012 - Creating a web-based incident analysis and communication system. … Creating a web-based incident analysis and communication system. … https://psnet.ahrq.gov/issue/creating-web-based-incident-analysis-and-communication-system This study … reports on the development of a system for standardizing root cause analysis of sentinel events. … /primer/root-cause-analysis https://psnet.ahrq.gov/primer/never-events

425. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43207/psn-pdf
     April 25, 2016 - Root cause analysis of serious adverse events among older patients in the Veterans Health Administration … Root cause analysis of serious adverse events among older patients in the Veterans Health Administration … https://psnet.ahrq.gov/issue/root-cause-analysis-serious-adverse-events-among-older-patients-veterans … Compared to previous research, this study highlights robust use of root cause analysis while emphasizing … https://psnet.ahrq.gov/issue/root-cause-analysis-serious-adverse-events-among-older-patients-veterans-health

426. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39520/psn-pdf
     June 10, 2018 - Building patient safety skills: common pitfalls when conducting a root cause analysis. … ://psnet.ahrq.gov/issue/building-patient-safety-skills-common-pitfalls-when-conducting-root-cause- analysis … This piece highlights common failures in root cause analysis (RCA) and explains how each undermines … https://psnet.ahrq.gov/issue/building-patient-safety-skills-common-pitfalls-when-conducting-root-cause-analysis … https://psnet.ahrq.gov/primer/root-cause-analysis

427. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41673/psn-pdf
     September 12, 2012 - A root cause analysis project in a medication safety course. September 12, 2012 Schafer JJ. … A root cause analysis project in a medication safety course. … an initiative to integrate development of root cause analysis skills into a pharmacy curriculum to … https://psnet.ahrq.gov/issue/root-cause-analysis-project-medication-safety-course https://psnet.ahrq.gov … /primer/root-cause-analysis https://psnet.ahrq.gov/issue/educating-safety

428. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41592/psn-pdf
     August 15, 2012 - Failure mode and effects analysis outputs: are they valid? … Failure mode and effects analysis outputs: are they valid? … https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-outputs-are-they-valid This study casts … doubt on the validity and reliability of failure mode and effect analysis, a commonly used tool to … /issue/healthcare-failure-mode-and-effect-analysis

429. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37784/psn-pdf
     May 27, 2011 - A risk analysis method to evaluate the impact of a Computerized Provider Order Entry system on patient … A risk analysis method to evaluate the impact of a computerized provider order entry system on patient … https://psnet.ahrq.gov/issue/risk-analysis-method-evaluate-impact-computerized-provider-order-entry- … This study conducted a detailed quantitative analysis, following a failure mode and effect analysis … https://psnet.ahrq.gov/issue/risk-analysis-method-evaluate-impact-computerized-provider-order-entry-system-patient-safety

430. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43595/psn-pdf
     November 19, 2014 - Patient safety in external beam radiotherapy—guidelines on risk assessment and analysis of adverse error-events … Patient safety in external beam radiotherapy - guidelines on risk assessment and analysis of adverse … https://psnet.ahrq.gov/issue/patient-safety-external-beam-radiotherapy-guidelines-risk-assessment-and- analysis-adverse … other safety concerns, adverse events are under-reported to voluntary reporting systems and root cause analysis … https://psnet.ahrq.gov/primer/reporting-patient-safety-events https://psnet.ahrq.gov/primer/root-cause-analysis

431. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44754/psn-pdf
     March 23, 2016 - Use of failure mode and effects analysis to improve emergency department handoff processes. … Use of Failure Mode and Effects Analysis to Improve Emergency Department Handoff Processes. … https://psnet.ahrq.gov/issue/use-failure-mode-and-effects-analysis-improve-emergency-department- handoff-processes … This commentary describes a project that used failure mode and effects analysis to identify weaknesses … https://psnet.ahrq.gov/issue/use-failure-mode-and-effects-analysis-improve-emergency-department-handoff-processes

432. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46188/psn-pdf
     June 21, 2017 - Death by suicide within 1 week of hospital discharge: a retrospective study of root cause analysis reports … Death by Suicide Within 1 Week of Hospital Discharge: A Retrospective Study of Root Cause Analysis Reports … psnet.ahrq.gov/issue/death-suicide-within-1-week-hospital-discharge-retrospective-study-root- cause-analysis … This review of root cause analysis reports about suicide within 7 days of discharge from inpatient … /psnet.ahrq.gov/issue/death-suicide-within-1-week-hospital-discharge-retrospective-study-root-cause-analysis

433. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41893/psn-pdf
     January 09, 2013 - Counting matters: lessons from the root cause analysis of a retained surgical item. … Counting matters: lessons from the root cause analysis of a retained surgical item. … https://psnet.ahrq.gov/issue/counting-matters-lessons-root-cause-analysis-retained-surgical-item Reporting … root cause analysis results from a retained surgical item case, this commentary identifies contributing … https://psnet.ahrq.gov/issue/counting-matters-lessons-root-cause-analysis-retained-surgical-item https

434. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40106/psn-pdf
     December 22, 2010 - Root cause analysis of transfusion error: identifying causes to implement changes. … Root cause analysis of transfusion error: identifying causes to implement changes. … https://psnet.ahrq.gov/issue/root-cause-analysis-transfusion-error-identifying-causes-implement-changes … This case review discusses how root cause analysis of human and systems failures can identify areas … https://psnet.ahrq.gov/primer/root-cause-analysis

435. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44917/psn-pdf
     November 30, 2016 - Canadian Incident Analysis Framework. November 30, 2016 Incident Analysis Collaborating Parties. … https://psnet.ahrq.gov/issue/canadian-incident-analysis-framework Performing incident analysis can help … https://psnet.ahrq.gov/issue/canadian-incident-analysis-framework https://psnet.ahrq.gov/primer/root-cause-analysis

436. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42590/psn-pdf
     August 02, 2015 - Health care-associated infections: a meta-analysis of costs and financial impact on the US health care … Health care-associated infections: a meta-analysis of costs and financial impact on the US health care … https://psnet.ahrq.gov/issue/health-care-associated-infections-meta-analysis-costs-and-financial-impact-us … This economic analysis combined a systematic review of estimates of costs attributable to HAIs with … https://psnet.ahrq.gov/issue/business-case-quality-case-studies-and-analysis

437. Wrong drug and wrong dose dispensing errors identified in pharmacist professional liability claims. | PSNet
     psnet.ahrq.gov/issue/wrong-drug-and-wrong-dose-dispensing-errors-identified-pharmacist-professional-liability
     August 31, 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.

438. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42236/psn-pdf
     May 01, 2013 - Nursing student medication errors: a case study using root cause analysis. … Nursing student medication errors: a case study using root cause analysis. … https://psnet.ahrq.gov/issue/nursing-student-medication-errors-case-study-using-root-cause-analysis … This commentary examines a medication error involving insulin using root case analysis to identify factors … https://psnet.ahrq.gov/issue/nursing-student-medication-errors-case-study-using-root-cause-analysis https

439. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37095/psn-pdf
     September 04, 2010 - Prospective error recording in surgery: an analysis of 1108 elective neurosurgical cases. … Prospective error recording in surgery: an analysis of 1108 elective neurosurgical cases. … https://psnet.ahrq.gov/issue/prospective-error-recording-surgery-analysis-1108-elective-neurosurgical … - cases This analysis of cases performed by a single neurosurgeon found that errors occurred frequently … https://psnet.ahrq.gov/issue/prospective-error-recording-surgery-analysis-1108-elective-neurosurgical-cases

440. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36868/psn-pdf
     August 29, 2011 - Quali-quantitative analysis: a new model for evaluation of unusual cases in hospital performance? … Quali-quantitative analysis: a new model for evaluation of unusual cases in hospital performance? … https://psnet.ahrq.gov/issue/quali-quantitative-analysis-new-model-evaluation-unusual-cases-hospital- … criteria of high-quality hospital error research and explores the potential of quali-quantitative analysis … https://psnet.ahrq.gov/issue/quali-quantitative-analysis-new-model-evaluation-unusual-cases-hospital-performance