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61. Analysis of results from event investigations in industrial and patient safety contexts. | PSNet
    psnet.ahrq.gov/issue/analysis-results-event-investigations-industrial-and-patient-safety-contexts
    July 06, 2022 - Commentary Analysis of results from event investigations in industrial and patient … Analysis of results from event investigations in industrial and patient safety contexts. … The primary purpose of incident reporting and analysis is to propose safety reforms . … Root cause analysis resulted in suggestions at the department or ward level. … Analysis of results from event investigations in industrial and patient safety contexts.

62. Adverse events associated with patient isolation: a systematic literature review and meta-analysis. | PSNet
    psnet.ahrq.gov/issue/adverse-events-associated-patient-isolation-systematic-literature-review-and-meta-analysis
    May 19, 2021 - Adverse events associated with patient isolation: a systematic literature review and meta-analysis. … A systematic review and meta-analysis. … A systematic review and meta-analysis. … A systematic review and meta-analysis. … September 28, 2022 Nurse well-being: a concept analysis.

63. Implementing root cause analysis and action: integrating human factors to create strong interventions and reduce risk of patient harm. | PSNet
    psnet.ahrq.gov/issue/implementing-root-cause-analysis-and-action-integrating-human-factors-create-strong
    December 23, 2020 - Study Implementing root cause analysis and action: integrating human factors to create … Implementing root cause analysis and action: integrating human factors to create strong interventions … Implementing root cause analysis and action: integrating human factors to create strong interventions … of patient safety and root cause analysis reports in the Veterans Health Administration. … for monitoring and analysis method in healthcare facilities: a systematic literature review.

64. 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.

65. Outcomes of medication misadventure among people with cognitive impairment or dementia: a systematic review and meta-analysis. | PSNet
    psnet.ahrq.gov/issue/outcomes-medication-misadventure-among-people-cognitive-impairment-or-dementia-systematic
    March 08, 2023 - medication misadventure among people with cognitive impairment or dementia: a systematic review and meta-analysis … medication misadventure among people with cognitive impairment or dementia: a systematic review and meta-analysis … This meta-analysis of five studies concluded that exposure to potentially inappropriate medications ( … and patient outcomes on transition from adult intensive care settings: a systematic review and meta-analysis … A systematic review and meta-analysis.

66. Root cause analysis of ICU adverse events in the Veterans Health Administration. | PSNet
    psnet.ahrq.gov/issue/root-cause-analysis-icu-adverse-events-veterans-health-administration
    June 23, 2021 - Study Root cause analysis of ICU adverse events in the Veterans Health Administration … Root Cause Analysis of ICU Adverse Events in the Veterans Health Administration. … Root cause analysis is widely utilized in health care to examine adverse events . … Root Cause Analysis of ICU Adverse Events in the Veterans Health Administration. … of patient safety and root cause analysis reports in the Veterans Health Administration.

67. Long-term care healthcare-associated infections in 2022: an analysis of 20,216 reports. | PSNet
    psnet.ahrq.gov/issue/long-term-care-healthcare-associated-infections-2022-analysis-20216-reports
    July 24, 2024 - Study Long-term care healthcare-associated infections in 2022: an analysis of 20,216 … Long-term care healthcare-associated iInfections in 2022: an analysis of 20,216 reports. … Based on incident data from the Pennsylvania Patient Safety Reporting System (PA-PSRS), this analysis … Long-term care healthcare-associated iInfections in 2022: an analysis of 20,216 reports. … July 8, 2020 Long-term care healthcare-associated infections in 2021: an analysis of

68. Root cause analysis to identify contributing factors for the development of hospital acquired pressure injuries. | PSNet
    psnet.ahrq.gov/issue/root-cause-analysis-identify-contributing-factors-development-hospital-acquired-pressure
    July 20, 2022 - Study Root cause analysis to identify contributing factors for the development of … Root cause analysis to identify contributing factors for the development of hospital acquired pressure … June 15, 2016 Root cause analysis for hospital-acquired pressure injury. … of patient safety and root cause analysis reports in the Veterans Health Administration. … September 30, 2020 Root cause analysis for hospital-acquired pressure injury.

69. Reducing failures in daily medical practice: healthcare failure mode and effect analysis combined with computer simulation. | PSNet
    psnet.ahrq.gov/issue/reducing-failures-daily-medical-practice-healthcare-failure-mode-and-effect-analysis-combined
    August 10, 2022 - Reducing failures in daily medical practice: healthcare failure mode and effect analysis … Reducing failures in daily medical practice: healthcare failure mode and effect analysis combined with … Failure mode and effect analysis (FMEA) is widely used to identify latent safety hazards. … The authors of this study proposed combining healthcare failure mode and effect analysis (HFMEA) with … A systematic review and meta-analysis.

70. 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

71. Trend analysis of radiation therapy incidents over seven years. | PSNet
    psnet.ahrq.gov/issue/trend-analysis-radiation-therapy-incidents-over-seven-years
    December 20, 2023 - Study Trend analysis of radiation therapy incidents over seven years. … Trend analysis of radiation therapy incidents over seven years. … Analysis of voluntary error reports indicated a decrease in safety incidents at a high-volume radiation … Trend analysis of radiation therapy incidents over seven years. … Medical Oncology Radiology Epidemiology of Errors and Adverse Events Error Reporting and Analysis

72. 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

73. 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.

74. 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.

75. Operationalizing occupational fatigue in pharmacists: an exploratory factor analysis. | PSNet
    psnet.ahrq.gov/issue/operationalizing-occupational-fatigue-pharmacists-exploratory-factor-analysis
    March 23, 2022 - Study Operationalizing occupational fatigue in pharmacists: an exploratory factor analysis … Operationalizing occupational fatigue in pharmacists: an exploratory factor analysis. … Using exploratory factor analysis, this study found physical and mental fatigue were the primary drivers … Operationalizing occupational fatigue in pharmacists: an exploratory factor analysis. … April 7, 2021 Using failure mode and effects analysis to increase patient safety in cancer

76. Qualitative content analysis: a framework for the substantive review of hospital incident reports. | PSNet
    psnet.ahrq.gov/issue/qualitative-content-analysis-framework-substantive-review-hospital-incident-reports
    March 16, 2022 - Commentary Qualitative content analysis: a framework for the substantive review of … Qualitative content analysis: a framework for the substantive review of hospital incident reports. … content analysis can support incident analysis and help identify risk mitigation strategies, performance … Qualitative content analysis: a framework for the substantive review of hospital incident reports. … March 11, 2020 Does root cause analysis improve patient safety?

77. Implementation of a mock root cause analysis to provide simulated patient safety training. | PSNet
    psnet.ahrq.gov/issue/implementation-mock-root-cause-analysis-provide-simulated-patient-safety-training
    January 12, 2022 - Commentary Implementation of a mock root cause analysis to provide simulated patient … Implementation of a mock root cause analysis to provide simulated patient safety training. … Root cause analysis is a strategy to identify and reduce risks, but there are concerns regarding its … Implementation of a mock root cause analysis to provide simulated patient safety training. … June 10, 2020 Simulation-based event analysis improves error discovery and generates

78. Optimizing measurement of misdiagnosis-related harms using symptom-disease pair analysis of diagnostic error (SPADE): comparison groups to maximize SPADE validity. | PSNet
    psnet.ahrq.gov/issue/optimizing-measurement-misdiagnosis-related-harms-using-symptom-disease-pair-analysis
    July 21, 2021 - Optimizing measurement of misdiagnosis-related harms using symptom-disease pair analysis … Optimizing measurement of misdiagnosis-related harms using symptom-disease pair analysis of diagnostic … Symptom–Disease Pair Analysis of Diagnostic Error (SPADE) is a framework to measure diagnostic errors … Optimizing measurement of misdiagnosis-related harms using symptom-disease pair analysis of diagnostic … with administrative claims data using Symptom-Disease Pair Analysis of Diagnostic Error methodology

79. Use of FMEA analysis to reduce risk of errors in prescribing and administering drugs in paediatric wards: a quality improvement report. | PSNet
    psnet.ahrq.gov/issue/use-fmea-analysis-reduce-risk-errors-prescribing-and-administering-drugs-paediatric-wards
    March 08, 2023 - Study Use of FMEA analysis to reduce risk of errors in prescribing and administering … Use of FMEA analysis to reduce risk of errors in prescribing and administering drugs in paediatric wards … Failure mode and effect analysis identified calculation errors as a major source of medication errors … Use of FMEA analysis to reduce risk of errors in prescribing and administering drugs in paediatric wards … December 9, 2020 The AMÉLIE project: failure mode, effects and criticality analysis:

80. 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.