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421. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44025/psn-pdf
     February 22, 2018 - The causes of their death appear (unto our shame perpetual): why root cause analysis is not the best … The Causes of Their Death Appear (Unto Our Shame Perpetual): Why Root Cause Analysis Is Not the Best … https://psnet.ahrq.gov/issue/causes-their-death-appear-unto-our-shame-perpetual-why-root-cause- analysis-not-best-model … Root cause analysis is a longstanding approach to in-depth investigation of adverse events, with evidence … method may not be helpful, their findings also emphasize the importance of implementing root cause analysis

422. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37562/psn-pdf
     June 14, 2011 - Effectiveness and efficiency of root cause analysis in medicine. June 14, 2011 Wu AW. … Effectiveness and Efficiency of Root Cause Analysis in Medicine. JAMA. 2008;299(6):685-687. … https://psnet.ahrq.gov/issue/effectiveness-and-efficiency-root-cause-analysis-medicine Application of … root cause analysis (RCA) continues to serve an important role in improving patient safety and quality … /primer/root-cause-analysis https://psnet.ahrq.gov/issue/veterans-affairs-root-cause-analysis-system-action

423. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40068/psn-pdf
     January 19, 2011 - Application of root cause analysis on malpractice claim files related to diagnostic failures. … Application of root cause analysis on malpractice claim files related to diagnostic failures. … https://psnet.ahrq.gov/issue/application-root-cause-analysis-malpractice-claim-files-related-diagnostic … - failures This study applied root cause analysis to cases of diagnostic failure, and discusses the … https://psnet.ahrq.gov/primer/root-cause-analysis https://psnet.ahrq.gov/primer/diagnostic-errors

424. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40060/psn-pdf
     December 15, 2010 - Failure mode and effects analysis: an empirical comparison of failure mode scoring procedures. … Failure Mode and Effects Analysis. J Patient Saf. 2010;6(4):210-215. … https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-empirical-comparison-failure-mode-scoring … - procedures This study empirically demonstrated that different failure mode effect analysis (FMEA) … https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-empirical-comparison-failure-mode-scoring-procedures

425. 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

426. 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.

427. 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.

428. 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

429. 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

430. 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

431. 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

432. 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.

433. 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

434. 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

435. 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

436. 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

437. 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

438. 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.

439. 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

440. 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