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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42670/psn-pdf
    January 09, 2014 - Meta-analysis of surgical safety checklist effects on teamwork, communication, morbidity, mortality, … Meta-analysis of surgical safety checklist effects on teamwork, communication, morbidity, mortality, … https://psnet.ahrq.gov/issue/meta-analysis-surgical-safety-checklist-effects-teamwork-communication- … morbidity-mortality This meta-analysis of 19 surgical checklist studies found that checklists improved … https://psnet.ahrq.gov/issue/meta-analysis-surgical-safety-checklist-effects-teamwork-communication-morbidity-mortality

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34794/psn-pdf
    November 18, 2015 - Accident analysis of large-scale technological disasters applied to an anaesthetic complication. … Accident analysis of large-scale technological disasters applied to an anaesthetic complication. … https://psnet.ahrq.gov/issue/accident-analysis-large-scale-technological-disasters-applied-anaesthetic … The model discussed focuses on two types of failures, which share equal importance in analysis but distinguish … They conclude that analysis of past disasters has offered a useful model to differentiate provider from

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39948/psn-pdf
    December 21, 2014 - Wrong-site and wrong-patient procedures in the Universal Protocol era: analysis of a prospective database … Wrong-site and wrong-patient procedures in the universal protocol era: analysis of a prospective database … https://psnet.ahrq.gov/issue/wrong-site-and-wrong-patient-procedures-universal-protocol-era-analysis- … However, this analysis of WSPEs that were voluntarily reported to a Colorado malpractice insurance company … Root cause analysis revealed a number of contributing causes, with diagnostic errors and communication

  4. National Patient Safety Goals. | PSNet

    psnet.ahrq.gov/issue/national-patient-safety-goals
    May 30, 2012 - 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.

  5. ISMP Targeted Medication Safety Best Practices for Community Pharmacy. | PSNet

    psnet.ahrq.gov/issue/ismp-targeted-medication-safety-best-practices-community-pharmacy
    March 21, 2012 - 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.

  6. Implementing a bar-code medication administration system. | PSNet

    psnet.ahrq.gov/issue/implementing-bar-code-medication-administration-system
    May 11, 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.

  7. Preventing harm from high-alert medications. | PSNet

    psnet.ahrq.gov/issue/preventing-harm-high-alert-medications
    August 14, 2017 - 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.

  8. Labeling morphine milligram equivalents on opioid packaging: a potential patient safety intervention. | PSNet

    psnet.ahrq.gov/issue/labeling-morphine-milligram-equivalents-opioid-packaging-potential-patient-safety
    March 06, 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.

  9. Predictors of warfarin-associated adverse events in hospitalized patients: opportunities to prevent patient harm. | PSNet

    psnet.ahrq.gov/issue/predictors-warfarin-associated-adverse-events-hospitalized-patients-opportunities-prevent
    August 03, 2016 - 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.

  10. Impact of a standard medication chart on prescribing errors: a before-and-after audit. | PSNet

    psnet.ahrq.gov/issue/impact-standard-medication-chart-prescribing-errors-and-after-audit
    May 02, 2012 - 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.

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35434/psn-pdf
    June 14, 2011 - Turning the medical gaze in upon itself: root cause analysis and the investigation of clinical error … Turning the medical gaze in upon itself: root cause analysis and the investigation of clinical error … https://psnet.ahrq.gov/issue/turning-medical-gaze-upon-itself-root-cause-analysis-and-investigation-clinical … - error This study discusses the translocation of root cause analysis (RCA) techniques from non-health … playing-well-others-translocational-research-patient-safety https://psnet.ahrq.gov/primer/root-cause-analysis

  12. The health information infrastructure in America today . . . . (pdf file)

    hcup-us.ahrq.gov/datainnovations/clinicaldata/AHRQHCUPfinalNov09BDiefenbach.pdf
    November 01, 2009 - Agency for Health Care Administration Florida Center for Health Information and Policy Analysis HCUP … Learned Agency for Health Care Administration Florida Center for Health Information and Policy Analysis … Hospital Agency for Health Care Administration Florida Center for Health Information and Policy Analysis … Agency for Health Care Administration Florida Center for Health Information and Policy Analysis Data … Agency for Health Care Administration Florida Center for Health Information and Policy Analysis LOINC

  13. 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

  14. 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

  15. 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

  16. 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

  17. 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

  18. 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:

  19. 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

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33825/psn-pdf
    January 01, 2017 - Rethinking Root Cause Analysis January 1, 2016 Gupta K, Lyndon A. Rethinking Root Cause Analysis. … https://psnet.ahrq.gov/perspective/rethinking-root-cause-analysis https://psnet.ahrq.gov/issue/effectiveness-and-efficiency-root-cause-analysis-medicine … Problems With Root Cause Analysis in Health Care 1. … The problem with root cause analysis. BMJ Qual Saf. 2017;26:417-422. … /canadian-incident-analysis-framework https://psnet.ahrq.gov/issue/canadian-incident-analysis-framework
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