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461. 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.

462. 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.

463. 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.

464. 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.

465. 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

466. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43022/psn-pdf
     May 29, 2014 - Using simulation to improve root cause analysis of adverse surgical outcomes. … Using simulation to improve root cause analysis of adverse surgical outcomes. … https://psnet.ahrq.gov/issue/using-simulation-improve-root-cause-analysis-adverse-surgical-outcomes … Comparing the use of case simulation with root cause analysis for investigating adverse surgical outcomes … ://psnet.ahrq.gov/primer/simulation-training https://psnet.ahrq.gov/primer/root-cause-analysis https:

467. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40729/psn-pdf
     October 04, 2011 - Critical incident reports concerning anaesthetic equipment: analysis of the UK National Reporting and … Critical incident reports concerning anaesthetic equipment: analysis of the UK National Reporting and … https://psnet.ahrq.gov/issue/critical-incident-reports-concerning-anaesthetic-equipment-analysis-uk- … national-reporting-and Analysis of critical incidents involving anesthesia equipment failure found … https://psnet.ahrq.gov/issue/critical-incident-reports-concerning-anaesthetic-equipment-analysis-uk-national-reporting-and

468. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43335/psn-pdf
     July 09, 2014 - Wake Up Safe and root cause analysis: quality improvement in pediatric anesthesia. … Wake Up Safe and root cause analysis: quality improvement in pediatric anesthesia. … https://psnet.ahrq.gov/issue/wake-safe-and-root-cause-analysis-quality-improvement-pediatric-anesthesia … This commentary provides an overview of root cause analysis methods and describes an initiative that … https://psnet.ahrq.gov/issue/wake-safe-and-root-cause-analysis-quality-improvement-pediatric-anesthesia

469. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37275/psn-pdf
     December 23, 2011 - Developing indicators of inpatient adverse drug events through nonlinear analysis using administrative … Developing indicators of inpatient adverse drug events through nonlinear analysis using administrative … https://psnet.ahrq.gov/issue/developing-indicators-inpatient-adverse-drug-events-through-nonlinear- analysis-using … This study demonstrated the value of hierarchically optimal classification tree analysis as a promising … https://psnet.ahrq.gov/issue/developing-indicators-inpatient-adverse-drug-events-through-nonlinear-analysis-using

470. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37861/psn-pdf
     June 25, 2008 - Adverse outcomes of blood transfusion in children: analysis of UK reports to the serious hazards of … Adverse outcomes of blood transfusion in children: analysis of UK reports to the serious hazards of … https://psnet.ahrq.gov/issue/adverse-outcomes-blood-transfusion-children-analysis-uk-reports-serious- … hazards-transfusion This analysis of data from a voluntary reporting system in Britain provides an … https://psnet.ahrq.gov/issue/adverse-outcomes-blood-transfusion-children-analysis-uk-reports-serious-hazards-transfusion

471. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36207/psn-pdf
     October 13, 2010 - Using failure mode and effects analysis to plan implementation of smart i.v. pump technology. … Using failure mode and effects analysis to plan implementation of smart i.v. pump technology. … https://psnet.ahrq.gov/issue/using-failure-mode-and-effects-analysis-plan-implementation-smart-iv-pump … - technology The authors describe their use of failure mode and effects analysis to inform the launch … https://psnet.ahrq.gov/issue/using-failure-mode-and-effects-analysis-plan-implementation-smart-iv-pump-technology

472. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42679/psn-pdf
     October 23, 2013 - An evidence-based toolkit for the development of effective and sustainable root cause analysis system … An evidence-based toolkit for the development of effective and sustainable root cause analysis system … https://psnet.ahrq.gov/issue/evidence-based-toolkit-development-effective-and-sustainable-root-cause- analysis-system … https://psnet.ahrq.gov/issue/evidence-based-toolkit-development-effective-and-sustainable-root-cause-analysis-system … https://psnet.ahrq.gov/primer/root-cause-analysis https://psnet.ahrq.gov/primer/systems-approach

473. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38343/psn-pdf
     December 09, 2014 - Liability associated with obstetric anesthesia: a closed claims analysis. … Liability associated with obstetric anesthesia: a closed claims analysis. … https://psnet.ahrq.gov/issue/liability-associated-obstetric-anesthesia-closed-claims-analysis The use … https://psnet.ahrq.gov/issue/liability-associated-obstetric-anesthesia-closed-claims-analysis https:/ … https://psnet.ahrq.gov/issue/adverse-respiratory-events-anesthesia-closed-claims-analysis

474. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41858/psn-pdf
     November 21, 2012 - Disorganized care: the findings of an iterative, in-depth analysis of surgical morbidity and mortality … Disorganized care: the findings of an iterative, in-depth analysis of surgical morbidity and mortality … https://psnet.ahrq.gov/issue/disorganized-care-findings-iterative-depth-analysis-surgical-morbidity-and … conferences over a 3-year period at one academic hospital and used insights from a modified root cause analysis … https://psnet.ahrq.gov/primer/systems-approach https://psnet.ahrq.gov/primer/root-cause-analysis https

475. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44967/psn-pdf
     March 16, 2016 - Wrong site surgery: a critical incident analysis of a near miss. March 16, 2016 Tichanow S. … Wrong site surgery: A critical incident analysis of a near miss. … https://psnet.ahrq.gov/issue/wrong-site-surgery-critical-incident-analysis-near-miss Despite efforts … https://psnet.ahrq.gov/issue/wrong-site-surgery-critical-incident-analysis-near-miss https://psnet.ahrq.gov … https://psnet.ahrq.gov/issue/using-near-misses-analysis-prevent-wrong-site-surgery https://psnet.ahrq.gov

476. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38727/psn-pdf
     November 25, 2009 - FMEA team performance in health care: a qualitative analysis of team member perceptions. … https://psnet.ahrq.gov/issue/fmea-team-performance-health-care-qualitative-analysis-team-member- perceptions … Failure mode and effect analysis (FMEA), a tool that allows prospective risk assessment, has been applied … https://psnet.ahrq.gov/issue/fmea-team-performance-health-care-qualitative-analysis-team-member-perceptions … https://psnet.ahrq.gov/issue/fmea-team-performance-health-care-qualitative-analysis-team-member-perceptions

477. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42329/psn-pdf
     December 18, 2014 - Health care failure mode and effect analysis to reduce NICU line–associated bloodstream infections. … Health care failure mode and effect analysis to reduce NICU line-associated bloodstream infections. … https://psnet.ahrq.gov/issue/health-care-failure-mode-and-effect-analysis-reduce-nicu-line-associated … - bloodstream Successful application of a failure mode and effect analysis approach resulted in a marked … https://psnet.ahrq.gov/issue/health-care-failure-mode-and-effect-analysis-reduce-nicu-line-associated-bloodstream

478. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39735/psn-pdf
     January 03, 2017 - A practical guide to Failure Mode and Effects Analysis in health care: making the most of the team and … A practical guide to Failure Mode and Effects Analysis in health care: making the most of the team and … https://psnet.ahrq.gov/issue/practical-guide-failure-mode-and-effects-analysis-health-care-making-most … team-and-its This commentary describes one hospital's experience implementing  Failure Mode and Effects Analysis … https://psnet.ahrq.gov/issue/practical-guide-failure-mode-and-effects-analysis-health-care-making-most-team-and-its

479. External Inquiry into the adverse incident that occurred at Queen's Medical Centre, Nottingham, 4th January 2001. | PSNet
     psnet.ahrq.gov/issue/external-inquiry-adverse-incident-occurred-queens-medical-centre-nottingham-4th-january-2001
     September 10, 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.

480. A crack in our best armor: "wrong patient" injections from insulin pens alarmingly frequent even with barcode scanning. | PSNet
     psnet.ahrq.gov/issue/crack-our-best-armor-wrong-patient-injections-insulin-pens-alarmingly-frequent-even-barcode
     October 22, 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. … May 29, 2019 ISMP medication error report analysis.