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9541. 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

9542. 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

9543. 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

9544. 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

9545. 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

9546. 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

9547. 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:

9548. 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

9549. 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

9550. 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

9551. 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

9552. 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

9553. 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

9554. 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

9555. 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

9556. 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

9557. 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

9558. 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

9559. 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

9560. 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: