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7041. 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:

7042. 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

7043. 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

7044. 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

7045. 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.

7046. 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.

7047. 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

7048. 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

7049. 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

7050. 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

7051. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45666/psn-pdf
      April 24, 2018 - The relationship between professional burnout and quality and safety in healthcare: a meta-analysis. … The Relationship Between Professional Burnout and Quality and Safety in Healthcare: A Meta-Analysis. … psnet.ahrq.gov/issue/relationship-between-professional-burnout-and-quality-and-safety-healthcare- meta-analysis … This meta-analysis examined the relationship of burnout to health care quality. … In the pooled analysis, higher levels of burnout were associated with lower reported quality and safety

7052. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38207/psn-pdf
      January 15, 2009 - Analysis of medical emergency team calls comparing subjective to "objective" call criteria. … Analysis of medical emergency team calls comparing subjective to "objective" call criteria. … https://psnet.ahrq.gov/issue/analysis-medical-emergency-team-calls-comparing-subjective-objective-call … This analysis conducted at six Australian hospitals found that nurses' general concern about a patient … https://psnet.ahrq.gov/issue/analysis-medical-emergency-team-calls-comparing-subjective-objective-call-criteria

7053. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42469/psn-pdf
      August 07, 2013 - Characteristics of paid malpractice claims settled in and out of court in the USA: a retrospective analysis … Characteristics of paid malpractice claims settled in and out of court in the USA: a retrospective analysis … psnet.ahrq.gov/issue/characteristics-paid-malpractice-claims-settled-and-out-court-usa- retrospective-analysis … This analysis of paid malpractice claims from the National Practitioner Data Bank found that the vast … psnet.ahrq.gov/issue/characteristics-paid-malpractice-claims-settled-and-out-court-usa-retrospective-analysis

7054. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43501/psn-pdf
      September 10, 2014 - Emergency department patient safety incident characterization: an observational analysis of the findings … Emergency department patient safety incident characterization: an observational analysis of the findings … /psnet.ahrq.gov/issue/emergency-department-patient-safety-incident-characterization-observational- analysis-findings … Analysis of the data revealed that most emergency department patient safety incidents were primarily … ://psnet.ahrq.gov/issue/emergency-department-patient-safety-incident-characterization-observational-analysis-findings

7055. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38735/psn-pdf
      June 24, 2009 - Reflection and analysis of how pharmacy students learn to communicate about medication errors. … Reflection and analysis of how pharmacy students learn to communicate about medication errors. … https://psnet.ahrq.gov/issue/reflection-and-analysis-how-pharmacy-students-learn-communicate-about- … https://psnet.ahrq.gov/issue/reflection-and-analysis-how-pharmacy-students-learn-communicate-about-medication-errors … https://psnet.ahrq.gov/issue/effectiveness-and-efficiency-root-cause-analysis-medicine https://psnet.ahrq.gov

7056. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43777/psn-pdf
      January 01, 2015 - Smartphones let surgeons know WhatsApp: an analysis of communication in emergency surgical teams. … Smartphones let surgeons know WhatsApp: an analysis of communication in emergency surgical teams. … https://psnet.ahrq.gov/issue/smartphones-let-surgeons-know-whatsapp-analysis-communication- emergency-surgical-teams … Analysis of messages found it to be a safe and efficient method of communication that was perceived … https://psnet.ahrq.gov/issue/smartphones-let-surgeons-know-whatsapp-analysis-communication-emergency-surgical-teams

7057. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43997/psn-pdf
      August 02, 2015 - Sentinel events, serious reportable events, and root cause analysis. … Sentinel events, serious reportable events, and root cause analysis. … https://psnet.ahrq.gov/issue/sentinel-events-serious-reportable-events-and-root-cause-analysis This … authors use ophthalmologic examples to illustrate the elements of a systematic approach to root cause analysis … https://psnet.ahrq.gov/issue/sentinel-events-serious-reportable-events-and-root-cause-analysis https:

7058. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43565/psn-pdf
      March 22, 2016 - The role of failure mode and effects analysis in health care. March 22, 2016 Fibuch E, Ahmed A. … The role of failure mode and effects analysis in health care. Physician Exec. 2014;40(4):28-32. … https://psnet.ahrq.gov/issue/role-failure-mode-and-effects-analysis-health-care Failure mode and effects … analysis (FMEA) has been recommended as a method to detect safety hazards and proactively address system … https://psnet.ahrq.gov/issue/role-failure-mode-and-effects-analysis-health-care https://psnet.ahrq.gov

7059. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47290/psn-pdf
      December 12, 2018 - Burnout in mental health professionals: a systematic review and meta-analysis of prevalence and determinants … Burnout in mental health professionals: a systematic review and meta- analysis of prevalence and determinants … https://psnet.ahrq.gov/issue/burnout-mental-health-professionals-systematic-review-and-meta-analysis- … This systematic review and meta-analysis found high rates of burnout among mental health professionals … https://psnet.ahrq.gov/issue/burnout-mental-health-professionals-systematic-review-and-meta-analysis-prevalence-and

7060. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41959/psn-pdf
      January 16, 2013 - Use of FMEA analysis to reduce risk of errors in prescribing and administering drugs in paediatric wards … Use of FMEA analysis to reduce risk of errors in prescribing and administering drugs in paediatric wards … https://psnet.ahrq.gov/issue/use-fmea-analysis-reduce-risk-errors-prescribing-and-administering-drugs … - paediatric-wards Failure mode and effect analysis identified calculation errors as a major source … https://psnet.ahrq.gov/issue/use-fmea-analysis-reduce-risk-errors-prescribing-and-administering-drugs-paediatric-wards