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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42701/psn-pdf
    June 27, 2018 - Improving reliability with root cause analysis. … June 27, 2018 Latino RJ https://psnet.ahrq.gov/issue/improving-reliability-root-cause-analysis This … article relates how root cause analysis, typically used after an adverse event, can be utilized as a … https://psnet.ahrq.gov/issue/improving-reliability-root-cause-analysis https://psnet.ahrq.gov/primer/ … root-cause-analysis

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34998/psn-pdf
    June 22, 2009 - Cause and effect analysis of closed claims in obstetrics and gynecology. … Cause and effect analysis of closed claims in obstetrics and gynecology. … https://psnet.ahrq.gov/issue/cause-and-effect-analysis-closed-claims-obstetrics-and-gynecology In the … The authors suggest that this method for analysis provides important opportunities for quality improvement … https://psnet.ahrq.gov/issue/cause-and-effect-analysis-closed-claims-obstetrics-and-gynecology

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43769/psn-pdf
    December 17, 2014 - Prospective risk analysis and incident reporting for better pharmaceutical care at paediatric hospital … Prospective risk analysis and incident reporting for better pharmaceutical care at paediatric hospital … https://psnet.ahrq.gov/issue/prospective-risk-analysis-and-incident-reporting-better-pharmaceutical-care … - paediatric Researchers performed prospective risk assessment using failure mode and effects analysis … https://psnet.ahrq.gov/issue/prospective-risk-analysis-and-incident-reporting-better-pharmaceutical-care-paediatric

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46728/psn-pdf
    March 27, 2018 - Near-miss event analysis enhances the barcode medication administration process. … https://psnet.ahrq.gov/issue/near-miss-event-analysis-enhances-barcode-medication-administration- process … and strategies that contributed to success such as promoting event reporting and applying root cause analysis … https://psnet.ahrq.gov/issue/near-miss-event-analysis-enhances-barcode-medication-administration-process … https://psnet.ahrq.gov/issue/near-miss-event-analysis-enhances-barcode-medication-administration-process

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43516/psn-pdf
    June 15, 2017 - Application of failure mode effect analysis to improve the care of septic patients admitted through … Application of Failure Mode Effect Analysis to Improve the Care of Septic Patients Admitted Through … https://psnet.ahrq.gov/issue/application-failure-mode-effect-analysis-improve-care-septic-patients-admitted … - through A multidisciplinary team employed failure mode and effect analysis methodology to detect … https://psnet.ahrq.gov/issue/application-failure-mode-effect-analysis-improve-care-septic-patients-admitted-through

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45131/psn-pdf
    July 20, 2016 - Systematic review and meta-analysis of educational interventions designed to improve medication administration … Systematic review and meta-analysis of educational interventions designed to improve medication administration … https://psnet.ahrq.gov/issue/systematic-review-and-meta-analysis-educational-interventions-designed- … This meta-analysis found that a broad range of nursing education interventions, from simulation to traditional … https://psnet.ahrq.gov/issue/systematic-review-and-meta-analysis-educational-interventions-designed-improve-medication

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45703/psn-pdf
    April 24, 2018 - Controlled interventions to reduce burnout in physicians: a systematic review and meta-analysis. … Controlled Interventions to Reduce Burnout in Physicians: A Systematic Review and Meta-analysis. … psnet.ahrq.gov/issue/controlled-interventions-reduce-burnout-physicians-systematic-review-and- meta-analysis … This systematic review and meta-analysis found that although interventions designed to mitigate burnout … /psnet.ahrq.gov/issue/controlled-interventions-reduce-burnout-physicians-systematic-review-and-meta-analysis

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43689/psn-pdf
    December 10, 2014 - A meta-analysis of the effectiveness of crew resource management training in acute care domains. … A meta-analysis of the effectiveness of crew resource management training in acute care domains. … https://psnet.ahrq.gov/issue/meta-analysis-effectiveness-crew-resource-management-training-acute-care … - domains This meta-analysis found that while there is clear evidence that team training had positive … https://psnet.ahrq.gov/issue/meta-analysis-effectiveness-crew-resource-management-training-acute-care-domains

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45824/psn-pdf
    January 25, 2017 - The detection, analysis, and significance of physician clustering in medical malpractice lawsuit payouts … The Detection, Analysis, and Significance of Physician Clustering in Medical Malpractice Lawsuit Payouts … https://psnet.ahrq.gov/issue/detection-analysis-and-significance-physician-clustering-medical-malpractice … https://psnet.ahrq.gov/issue/detection-analysis-and-significance-physician-clustering-medical-malpractice-lawsuit-payouts … https://psnet.ahrq.gov/issue/detection-analysis-and-significance-physician-clustering-medical-malpractice-lawsuit-payouts

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43383/psn-pdf
    August 13, 2014 - Risk factors for retained surgical items: a meta-analysis and proposed risk stratification system. … Risk factors for retained surgical items: a meta-analysis and proposed risk stratification system. … https://psnet.ahrq.gov/issue/risk-factors-retained-surgical-items-meta-analysis-and-proposed-risk- stratification-system … This meta-analysis identified factors that increase risk of retained foreign objects, including clinical … https://psnet.ahrq.gov/issue/risk-factors-retained-surgical-items-meta-analysis-and-proposed-risk-stratification-system

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46506/psn-pdf
    October 11, 2017 - Getting Ahead of Harm Before It Happens: A Guide About Proactive Analysis for Improving Surgical Care … https://psnet.ahrq.gov/issue/getting-ahead-harm-it-happens-guide-about-proactive-analysis-improving- … surgical-care-safety Proactive analysis can help uncover process weaknesses and ensure improvements … This guide provides insights for organizations who seek to implement proactive analysis strategies. … https://psnet.ahrq.gov/issue/getting-ahead-harm-it-happens-guide-about-proactive-analysis-improving-surgical-care-safety

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43154/psn-pdf
    August 22, 2016 - Root cause analysis of ambulatory adverse drug events that present to the emergency department. … Root Cause Analysis of Ambulatory Adverse Drug Events That Present to the Emergency Department. … https://psnet.ahrq.gov/issue/root-cause-analysis-ambulatory-adverse-drug-events-present-emergency- department … https://psnet.ahrq.gov/issue/root-cause-analysis-ambulatory-adverse-drug-events-present-emergency-department … https://psnet.ahrq.gov/issue/root-cause-analysis-ambulatory-adverse-drug-events-present-emergency-department

  13. Events associated with the prescribing, dispensing, and administering of medication loading doses. | PSNet

    psnet.ahrq.gov/issue/events-associated-prescribing-dispensing-and-administering-medication-loading-doses
    September 18, 2013 - 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 5, 2018 ISMP medication error report analysis.

  14. Keeping patients safe from iatrogenic methadone overdoses. | PSNet

    psnet.ahrq.gov/issue/keeping-patients-safe-iatrogenic-methadone-overdoses
    February 27, 2019 - 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.

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37327/psn-pdf
    March 03, 2011 - Patterns of technical error among surgical malpractice claims: an analysis of strategies to prevent … Patterns of technical error among surgical malpractice claims: an analysis of strategies to prevent … https://psnet.ahrq.gov/issue/patterns-technical-error-among-surgical-malpractice-claims-analysis- strategies-prevent-injury … https://psnet.ahrq.gov/issue/patterns-technical-error-among-surgical-malpractice-claims-analysis-strategies-prevent-injury … https://psnet.ahrq.gov/issue/injury-and-liability-associated-monitored-anesthesia-care-closed-claims-analysis

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35762/psn-pdf
    January 02, 2017 - Using Failure Mode and Effects Analysis for safe administration of chemotherapy to hospitalized children … Using Failure Mode and Effects Analysis for safe administration of chemotherapy to hospitalized children … https://psnet.ahrq.gov/issue/using-failure-mode-and-effects-analysis-safe-administration-chemotherapy … hospitalized This study discusses the experiences of a single institution in using failure mode and effects analysis … https://psnet.ahrq.gov/issue/using-failure-mode-and-effects-analysis-safe-administration-chemotherapy-hospitalized

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38911/psn-pdf
    September 09, 2009 - Radiology failure mode and effect analysis: what is it? September 9, 2009 Abujudeh H, Kaewlai R. … Radiology failure mode and effect analysis: what is it? … https://psnet.ahrq.gov/issue/radiology-failure-mode-and-effect-analysis-what-it This article introduces … the concept of failure mode and effect analysis, outlines the process, and discusses its use in radiologic … https://psnet.ahrq.gov/issue/radiology-failure-mode-and-effect-analysis-what-it https://psnet.ahrq.gov

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37623/psn-pdf
    April 18, 2011 - Human factors in anaesthetic practice: insights from a task analysis. … Human factors in anaesthetic practice: insights from a task analysis. … https://psnet.ahrq.gov/issue/human-factors-anaesthetic-practice-insights-task-analysis Human factors … analysis of anesthesiologists' activities revealed several areas where the potential for error could … https://psnet.ahrq.gov/issue/human-factors-anaesthetic-practice-insights-task-analysis https://psnet.ahrq.gov

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33972/psn-pdf
    June 14, 2011 - Maximize Patient Safety with Advanced Root Cause Analysis. … ISBN: 1578393485 https://psnet.ahrq.gov/issue/maximize-patient-safety-advanced-root-cause-analysis … A "how-to" book for organizations that have already implemented a root cause analysis (RCA) process in … https://psnet.ahrq.gov/issue/maximize-patient-safety-advanced-root-cause-analysis https://psnet.ahrq.gov … /primer/root-cause-analysis

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40609/psn-pdf
    July 13, 2011 - Human reliability analysis: a critique and review for managers. … Human reliability analysis: A critique and review for managers. … https://psnet.ahrq.gov/issue/human-reliability-analysis-critique-and-review-managers This review discusses … how human reliability analysis methodologies can be developed to improve safety in complex systems. … https://psnet.ahrq.gov/issue/human-reliability-analysis-critique-and-review-managers https://psnet.ahrq.gov
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