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441. 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

442. 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

443. 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

444. 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

445. 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

446. 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

447. Predictors of warfarin-associated adverse events in hospitalized patients: opportunities to prevent patient harm. | PSNet
     psnet.ahrq.gov/issue/predictors-warfarin-associated-adverse-events-hospitalized-patients-opportunities-prevent
     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.

448. Impact of a standard medication chart on prescribing errors: a before-and-after audit. | PSNet
     psnet.ahrq.gov/issue/impact-standard-medication-chart-prescribing-errors-and-after-audit
     May 02, 2012 - 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.

449. 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

450. 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

451. 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

452. 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

453. Implementing a bar-code medication administration system. | PSNet
     psnet.ahrq.gov/issue/implementing-bar-code-medication-administration-system
     May 11, 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.

454. Preventing harm from high-alert medications. | PSNet
     psnet.ahrq.gov/issue/preventing-harm-high-alert-medications
     August 14, 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.

455. National Patient Safety Goals. | PSNet
     psnet.ahrq.gov/issue/national-patient-safety-goals
     May 30, 2012 - 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.

456. ISMP Targeted Medication Safety Best Practices for Community Pharmacy. | PSNet
     psnet.ahrq.gov/issue/ismp-targeted-medication-safety-best-practices-community-pharmacy
     March 21, 2012 - 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.

457. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39948/psn-pdf
     December 21, 2014 - Wrong-site and wrong-patient procedures in the Universal Protocol era: analysis of a prospective database … Wrong-site and wrong-patient procedures in the universal protocol era: analysis of a prospective database … https://psnet.ahrq.gov/issue/wrong-site-and-wrong-patient-procedures-universal-protocol-era-analysis- … However, this analysis of WSPEs that were voluntarily reported to a Colorado malpractice insurance company … Root cause analysis revealed a number of contributing causes, with diagnostic errors and communication

458. 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

459. 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

460. 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