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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. 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.

423. 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

424. 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

425. 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

426. 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

427. 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

428. 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

429. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33825/psn-pdf
     January 01, 2017 - Rethinking Root Cause Analysis January 1, 2016 Gupta K, Lyndon A. Rethinking Root Cause Analysis. … https://psnet.ahrq.gov/perspective/rethinking-root-cause-analysis https://psnet.ahrq.gov/issue/effectiveness-and-efficiency-root-cause-analysis-medicine … Problems With Root Cause Analysis in Health Care 1. … The problem with root cause analysis. BMJ Qual Saf. 2017;26:417-422. … /canadian-incident-analysis-framework https://psnet.ahrq.gov/issue/canadian-incident-analysis-framework

430. 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

431. 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

432. 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

433. 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

434. 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

435. 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.

436. 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

437. 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

438. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38383/psn-pdf
     June 30, 2011 - A system analysis of a suboptimal surgical experience. … A system analysis of a suboptimal surgical experience. … https://psnet.ahrq.gov/issue/system-analysis-suboptimal-surgical-experience A post-surgical complication … https://psnet.ahrq.gov/issue/system-analysis-suboptimal-surgical-experience https://psnet.ahrq.gov/primer … /root-cause-analysis

439. 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

440. 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