AHRQ Search | Home Page

Rate of sepsis hospitalizations after misdiagnosis in adult emergency department patients: a look-forward analysis with administrative claims data using Symptom-Disease Pair Analysis of Diagnostic Error methodology in an integrated health system. | PSNet

psnet.ahrq.gov/issue/rate-sepsis-hospitalizations-after-misdiagnosis-adult-emergency-department-patients-look

December 08, 2021 - of sepsis hospitalizations after misdiagnosis in adult emergency department patients: a look-forward analysis … with administrative claims data using Symptom-Disease Pair Analysis of Diagnostic Error methodology … with administrative claims data using Symptom-Disease Pair Analysis of Diagnostic Error methodology … This study used a Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) “look-forward” analysis … with administrative claims data using Symptom-Disease Pair Analysis of Diagnostic Error methodology

Nursing surveillance: a concept analysis | PSNet

psnet.ahrq.gov/issue/nursing-surveillance-concept-analysis

May 26, 2021 - Review Nursing surveillance: a concept analysis Citation Text: Halverson … Nursing surveillance: a concept analysis. Nurs Forum. 2022;57(3):454-460. doi:10.1111/nuf.12702. … Nursing surveillance: a concept analysis.

Content analysis of patient complaints. | PSNet

psnet.ahrq.gov/issue/content-analysis-patient-complaints

January 18, 2023 - Study Content analysis of patient complaints. … Content analysis of patient complaints. … Content analysis of patient complaints. … October 13, 2018 Evolving factors in hospital safety: a systematic review and meta-analysis … 2017 Structuring patient and family involvement in medical error event disclosure and analysis

Medication communication: a concept analysis. | PSNet

psnet.ahrq.gov/issue/medication-communication-concept-analysis

June 16, 2021 - Review Medication communication: a concept analysis. … Medication communication: a concept analysis. … Medication communication: a concept analysis. … Engaging with ethnic minority consumers to improve safety in cancer services: a national stakeholder analysis

Use of dimensional analysis to reduce medication errors. | PSNet

psnet.ahrq.gov/issue/use-dimensional-analysis-reduce-medication-errors

August 06, 2014 - Study Use of dimensional analysis to reduce medication errors. … Citation Text: Use of dimensional analysis to reduce medication errors. … students on medication dosage calculation and found that those students who were taught using dimensional analysis … URL Cite Citation Citation Text: Use of dimensional analysis

Root Cause Analysis Workbook for Community/Ambulatory Pharmacy. | PSNet

psnet.ahrq.gov/issue/root-cause-analysis-workbook-communityambulatory-pharmacy

June 07, 2017 - Book/Report Root Cause Analysis Workbook for Community/Ambulatory Pharmacy. … Citation Text: Root Cause Analysis Workbook for Community/Ambulatory Pharmacy. … Root cause analysis offers a structured way to detect and address system weaknesses . … This workbook illustrates how root cause analysis can be applied to community pharmacy services to … February 6, 2019 ISMP Gap Analysis Tool (GAT) for Safe IV Push Medication Practices.

Systems Analysis of Critical Incidents: the London Protocol. | PSNet

psnet.ahrq.gov/issue/systems-analysis-critical-incidents-london-protocol

April 06, 2016 - Book/Report Systems Analysis of Critical Incidents: the London Protocol. … Citation Text: Systems Analysis of Critical Incidents: the London Protocol. … This revised report documents a process for adverse event analysis that risk managers and others may … Copy URL Cite Citation Citation Text: Systems Analysis … May 24, 2015 Systematic Systems Analysis: A Practical Approach to Patient Safety Reviews

A tool for the concise analysis of patient safety incidents. | PSNet

psnet.ahrq.gov/issue/tool-concise-analysis-patient-safety-incidents

August 09, 2018 - Study A tool for the concise analysis of patient safety incidents. … A Tool for the Concise Analysis of Patient Safety Incidents. … In this study, researchers tested a concise incident analysis method, drawing on multiple existing incident … investigation frameworks including the Canadian Incident Analysis Framework and the WHO High 5s program … A Tool for the Concise Analysis of Patient Safety Incidents.

Systematic root cause analysis of adverse drug events in a tertiary referral hospital. | PSNet

psnet.ahrq.gov/issue/systematic-root-cause-analysis-adverse-drug-events-tertiary-referral-hospital

November 16, 2022 - Study Classic Systematic root cause analysis of adverse … 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 … Systematic Root Cause Analysis of Adverse Drug Events in a Tertiary Referral Hospital.

A case of transfusion error in a trauma patient with subsequent root cause analysis leading to institutional change. | PSNet

psnet.ahrq.gov/issue/case-transfusion-error-trauma-patient-subsequent-root-cause-analysis-leading-institutional

March 30, 2022 - Commentary A case of transfusion error in a trauma patient with subsequent root cause analysis … A case of transfusion error in a trauma patient with subsequent root cause analysis leading to institutional … findings of the subsequent root cause analysis , which determined training weaknesses, time pressures … April 6, 2022 Root cause analysis to identify contributing factors for the development … September 23, 2020 Application of failure mode effect analysis to improve the care of

A risk analysis method to evaluate the impact of a Computerized Provider Order Entry system on patient safety. | PSNet

psnet.ahrq.gov/issue/risk-analysis-method-evaluate-impact-computerized-provider-order-entry-system-patient-safety

September 15, 2021 - Study A risk analysis method to evaluate the impact of a Computerized Provider Order … A risk analysis method to evaluate the impact of a computerized provider order entry system on patient … This study conducted a detailed quantitative analysis, following a failure mode and effect analysis ( … A risk analysis method to evaluate the impact of a computerized provider order entry system on patient … A systematic review and meta-analysis.

Simulation-based event analysis improves error discovery and generates improved strategies for error prevention. | PSNet

psnet.ahrq.gov/issue/simulation-based-event-analysis-improves-error-discovery-and-generates-improved-strategies

July 07, 2021 - Study Simulation-based event analysis improves error discovery and generates improved … Simulation-based event analysis improves error discovery and generates improved strategies for error … Root cause analysis (RCA) is a vital tool to assess errors and prevent their recurrence . … Simulation-based event analysis improves error discovery and generates improved strategies for error … for monitoring and analysis method in healthcare facilities: a systematic literature review.

Evaluation of the suitability of root cause analysis frameworks for the investigation of community-acquired pressure ulcers: a systematic review and documentary analysis. | PSNet

psnet.ahrq.gov/issue/evaluation-suitability-root-cause-analysis-frameworks-investigation-community-acquired

June 16, 2021 - Review Evaluation of the suitability of root cause analysis frameworks for the investigation … of community-acquired pressure ulcers: a systematic review and documentary analysis. … pressure ulcers: a systematic review and documentary analysis. … pressure ulcers: a systematic review and documentary analysis. … July 7, 2021 Root cause analysis for hospital-acquired pressure injury.

Analysis of paediatric long-term ventilation incidents in the community | PSNet

psnet.ahrq.gov/issue/analysis-paediatric-long-term-ventilation-incidents-community

November 06, 2024 - Study Analysis of paediatric long-term ventilation incidents in the community … Analysis of paediatric long-term ventilation incidents in the community. … This analysis of 220 national incident data from England and Wales’ National Reporting and Learning … Analysis of paediatric long-term ventilation incidents in the community. … February 17, 2016 Developing person-centred analysis of harm in a paediatric hospital

Antecedent treat-and-release diagnoses prior to sepsis hospitalization among adult emergency department patients: a look-back analysis employing insurance claims data using Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) methodology. | PSNet

psnet.ahrq.gov/issue/antecedent-treat-and-release-diagnoses-prior-sepsis-hospitalization-among-adult-emergency

May 12, 2021 - employing insurance claims data using Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) methodology … employing insurance claims data using Symptom-Disease Pair Analysis of Diagnostic Error (SPADE)…. … employing insurance claims data using Symptom-Disease Pair Analysis of Diagnostic Error (SPADE)…. … with administrative claims data using Symptom-Disease Pair Analysis of Diagnostic Error methodology … diagnostic errors in the emergency department: an analysis of serious adverse event reports.

The RCA ReCAst: a root cause analysis simulation for the interprofessional clinical learning environment. | PSNet

psnet.ahrq.gov/issue/rca-recast-root-cause-analysis-simulation-interprofessional-clinical-learning-environment

May 18, 2022 - Study The RCA ReCAst: a root cause analysis simulation for the interprofessional … The RCA ReCAst: a root cause analysis simulation for the interprofessional clinical learning environment … Root cause analysis (RCA) is a common method to investigate adverse events and identify contributing … program using root cause analysis and common cause analysis. … of patient safety and root cause analysis reports in the Veterans Health Administration.

Hemodialysis bleeding events and deaths: an 18-year retrospective analysis of patient safety and root cause analysis reports in the Veterans Health Administration. | PSNet

psnet.ahrq.gov/issue/hemodialysis-bleeding-events-and-deaths-18-year-retrospective-analysis-patient-safety-and

June 23, 2021 - Study Hemodialysis bleeding events and deaths: an 18-year retrospective analysis … of patient safety and root cause analysis reports in the Veterans Health Administration. … Hemodialysis bleeding events and deaths: an 18-year retrospective analysis of patient safety and root … cause analysis reports in the Veterans Health Administration. … cause analysis reports in the Veterans Health Administration.

ISMP medication error report analysis. | PSNet

psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-4

October 25, 2023 - Commentary ISMP medication error report analysis. … Citation Text: ISMP medication error report analysis. Cohen M. … April 6, 2016 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis.

Root Cause Analysis: Advanced Principles and Practices. | PSNet

psnet.ahrq.gov/issue/root-cause-analysis-advanced-principles-and-practices

October 06, 2022 - International Meeting/Conference Root Cause Analysis: Advanced Principles and Practices … September 29, 2022. 12:00pm-5:00pm (EST) Root cause analysis (RCA) is an established adverse … will introduce RCA techniques, patient communication strategies and the importance of appropriate post-analysis

Special Section: Event Analysis and Risk Management. | PSNet

psnet.ahrq.gov/issue/special-section-event-analysis-and-risk-management

March 11, 2020 - Book/Report Special Section: Event Analysis and Risk Management. … Citation Text: Special Section: Event Analysis and Risk Management. Alemi F ed. … Adverse event analysis is core for organizational learning from poor performance. … This special section discusses how examination tools such as failure mode and effect analysis and root … cause analysis may be amended to optimize how lessons can be drawn from failure to inform improvement

Search AHRQ

Results