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441. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40004/psn-pdf
     February 01, 2011 - Application of failure mode and effect analysis in a radiology department. … Application of Failure Mode and Effect Analysis in a Radiology Department. … https://psnet.ahrq.gov/issue/application-failure-mode-and-effect-analysis-radiology-department This … commentary introduces the failure mode and effects analysis process developed by the United States Department … https://psnet.ahrq.gov/issue/application-failure-mode-and-effect-analysis-radiology-department https:

442. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35322/psn-pdf
     July 14, 2009 - Safe chemotherapy administration: using failure mode and effects analysis in computerized prescriber … Safe chemotherapy administration: Using failure mode and effects analysis in computerized prescriber … https://psnet.ahrq.gov/issue/safe-chemotherapy-administration-using-failure-mode-and-effects-analysis … - computerized This case study describes one hospital’s use of failure mode and effects analysis (FMEA … https://psnet.ahrq.gov/issue/safe-chemotherapy-administration-using-failure-mode-and-effects-analysis-computerized

443. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36800/psn-pdf
     August 26, 2011 - Application of the human factors analysis and classification system methodology to the cardiovascular … Application of the human factors analysis and classification system methodology to the cardiovascular … https://psnet.ahrq.gov/issue/application-human-factors-analysis-and-classification-system-methodology … - cardiovascular The authors adapted an incident analysis model used in aviation to understand the … https://psnet.ahrq.gov/issue/application-human-factors-analysis-and-classification-system-methodology-cardiovascular

444. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39865/psn-pdf
     May 28, 2014 - Failure Mode and Effects Analysis in Health Care: Proactive Risk Reduction, Third Edition. … https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-health-care-proactive-risk-reduction-third … edition This publication provides strategies for organizations to utilize the Failure Mode and Effects Analysis … https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-health-care-proactive-risk-reduction-third-edition … https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-health-care-proactive-risk-reduction-third-edition

445. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44909/psn-pdf
     March 23, 2016 - Root Cause Analysis Workbook for Community/Ambulatory Pharmacy. … https://psnet.ahrq.gov/issue/root-cause-analysis-workbook-communityambulatory-pharmacy Root cause analysis … This workbook illustrates how root cause analysis can be applied to community pharmacy services to identify … https://psnet.ahrq.gov/issue/root-cause-analysis-workbook-communityambulatory-pharmacy https://psnet.ahrq.gov … /primer/root-cause-analysis https://psnet.ahrq.gov/issue/dispensing-errors-community-pharmacy-perceived-influence-sociotechnical-factors

446. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43795/psn-pdf
     December 17, 2014 - Systematic Systems Analysis: A Practical Approach to Patient Safety Reviews. … https://psnet.ahrq.gov/issue/systematic-systems-analysis-practical-approach-patient-safety-reviews Drawing … from human factors and system analysis techniques, this guide describes an approach to identifying … https://psnet.ahrq.gov/issue/systematic-systems-analysis-practical-approach-patient-safety-reviews https … https://psnet.ahrq.gov/issue/cross-sectional-analysis-investigating-organizational-factors-influence-near-miss-error

447. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39091/psn-pdf
     June 28, 2011 - Integration of prospective and retrospective methods for risk analysis in hospitals. … Integration of prospective and retrospective methods for risk analysis in hospitals. … https://psnet.ahrq.gov/issue/integration-prospective-and-retrospective-methods-risk-analysis-hospitals … https://psnet.ahrq.gov/issue/integration-prospective-and-retrospective-methods-risk-analysis-hospitals … https://psnet.ahrq.gov/primer/root-cause-analysis

448. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37086/psn-pdf
     October 03, 2011 - Failure mode and effects analysis: a useful tool for risk identification and injury prevention. … Failure mode and effects analysis: a useful tool for risk identification and injury prevention. … https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-useful-tool-risk-identification-and-injury … proactive risk assessment and provides insights on the successful use of failure mode and effects analysis … https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-useful-tool-risk-identification-and-injury-prevention

449. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34794/psn-pdf
     November 18, 2015 - Accident analysis of large-scale technological disasters applied to an anaesthetic complication. … Accident analysis of large-scale technological disasters applied to an anaesthetic complication. … https://psnet.ahrq.gov/issue/accident-analysis-large-scale-technological-disasters-applied-anaesthetic … The model discussed focuses on two types of failures, which share equal importance in analysis but distinguish … They conclude that analysis of past disasters has offered a useful model to differentiate provider from

450. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41554/psn-pdf
     January 03, 2017 - Using root cause analysis to reduce falls with injury in community settings. … Using root cause analysis to reduce falls with injury in community settings. … https://psnet.ahrq.gov/issue/using-root-cause-analysis-reduce-falls-injury-community-settings This study … used root cause analysis (RCA) to identify hazards leading to falls among community-dwelling elderly … /psnet.ahrq.gov/primer/root-cause-analysis https://psnet.ahrq.gov/primer/ambulatory-care-safety

451. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38753/psn-pdf
     July 01, 2009 - Evaluation of safety in a radiation oncology setting using failure mode and effects analysis. … Evaluation of safety in a radiation oncology setting using failure mode and effects analysis. … /psnet.ahrq.gov/issue/evaluation-safety-radiation-oncology-setting-using-failure-mode-and-effects- analysis … Failure mode and effects analysis was used to prospectively analyze an external beam radiation therapy … ://psnet.ahrq.gov/issue/evaluation-safety-radiation-oncology-setting-using-failure-mode-and-effects-analysis

452. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42670/psn-pdf
     January 09, 2014 - Meta-analysis of surgical safety checklist effects on teamwork, communication, morbidity, mortality, … Meta-analysis of surgical safety checklist effects on teamwork, communication, morbidity, mortality, … https://psnet.ahrq.gov/issue/meta-analysis-surgical-safety-checklist-effects-teamwork-communication- … morbidity-mortality This meta-analysis of 19 surgical checklist studies found that checklists improved … https://psnet.ahrq.gov/issue/meta-analysis-surgical-safety-checklist-effects-teamwork-communication-morbidity-mortality

453. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44339/psn-pdf
     July 29, 2015 - Rapid response systems: a systematic review and meta- analysis. … Rapid response systems: a systematic review and meta-analysis. … https://psnet.ahrq.gov/issue/rapid-response-systems-systematic-review-and-meta-analysis This meta-analysis … This analysis supports the current widespread implementation of rapid response. … https://psnet.ahrq.gov/issue/rapid-response-systems-systematic-review-and-meta-analysis https://psnet.ahrq.gov

454. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40218/psn-pdf
     December 29, 2014 - Preventable adverse drug events and their causes and contributing factors: the analysis of register … Preventable adverse drug events and their causes and contributing factors: the analysis of register … ://psnet.ahrq.gov/issue/preventable-adverse-drug-events-and-their-causes-and-contributing-factors- analysis-register … https://psnet.ahrq.gov/issue/preventable-adverse-drug-events-and-their-causes-and-contributing-factors-analysis-register … https://psnet.ahrq.gov/issue/preventable-adverse-drug-events-and-their-causes-and-contributing-factors-analysis-register

455. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36331/psn-pdf
     October 26, 2010 - Using system analysis to build a safety culture: improving the reliability of epidural analgesia. … Using system analysis to build a safety culture: improving the reliability of epidural analgesia. … https://psnet.ahrq.gov/issue/using-system-analysis-build-safety-culture-improving-reliability-epidural … - analgesia The authors describe the systematic analysis of an incident involving inappropriate use … https://psnet.ahrq.gov/issue/using-system-analysis-build-safety-culture-improving-reliability-epidural-analgesia

456. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37132/psn-pdf
     June 14, 2011 - Preventing medication errors in community pharmacy: root-cause analysis of transcription errors. … Preventing medication errors in community pharmacy: root- cause analysis of transcription errors. … https://psnet.ahrq.gov/issue/preventing-medication-errors-community-pharmacy-root-cause-analysis- transcription-errors … https://psnet.ahrq.gov/issue/preventing-medication-errors-community-pharmacy-root-cause-analysis-transcription-errors … https://psnet.ahrq.gov/primer/root-cause-analysis https://psnet.ahrq.gov//#adversedrugevent

457. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35434/psn-pdf
     June 14, 2011 - Turning the medical gaze in upon itself: root cause analysis and the investigation of clinical error … Turning the medical gaze in upon itself: root cause analysis and the investigation of clinical error … https://psnet.ahrq.gov/issue/turning-medical-gaze-upon-itself-root-cause-analysis-and-investigation-clinical … - error This study discusses the translocation of root cause analysis (RCA) techniques from non-health … playing-well-others-translocational-research-patient-safety https://psnet.ahrq.gov/primer/root-cause-analysis

458. 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

459. 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.

460. 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.