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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866082/psn-pdf
    June 05, 2024 - Putting the "action" in RCA(2): an analysis of intervention strength after adverse events. … Putting the "action" in RCA(2): an analysis of intervention strength after adverse events. … https://psnet.ahrq.gov/issue/putting-action-rca2-analysis-intervention-strength-after-adverse-events … This analysis of 67 safety events reported at one academic medical center between 2020 and 2021 explored … https://psnet.ahrq.gov/issue/putting-action-rca2-analysis-intervention-strength-after-adverse-events

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865817/psn-pdf
    May 08, 2024 - Using Healthcare Failure Mode and Effect Analysis in prospective medication safety risk management in … Using Healthcare Failure Mode and Effect Analysis in prospective medication safety risk management in … https://psnet.ahrq.gov/issue/using-healthcare-failure-mode-and-effect-analysis-prospective-medication … In this study, a hospital used Healthcare Failure Mode and Effect Analysis (HFMEA) to prospectively … https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-reduce-risk-heparin-use https://psnet.ahrq.gov

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48134/psn-pdf
    August 14, 2019 - Root cause analysis for hospital-acquired pressure injury. August 14, 2019 Black JM. … Root cause analysis for hospital-acquired pressure injury. … https://psnet.ahrq.gov/issue/root-cause-analysis-hospital-acquired-pressure-injury Pressure injuries … The author suggests that common cause analysis is an effective method to utilize root cause analysis … /psnet.ahrq.gov/issue/common-cause-analysis

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73371/psn-pdf
    June 09, 2021 - Reducing failures in daily medical practice: healthcare failure mode and effect analysis combined with … 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 … https://psnet.ahrq.gov/issue/augmenting-health-care-failure-modes-and-effects-analysis-simulation https

  5. Levy, Douglas | Digital Healthcare Research

    digital.ahrq.gov/principal-investigator/levy-douglas
    January 01, 2023 - Health IT-assisted population-based preventive cancer screening: a cost analysis … Health IT-assisted population-based preventive cancer screening: a cost analysis. … Principal Investigator Levy, Douglas Project Name Economic Analysis of an Information … Technology-Assisted Population-Based Cancer Screening Program Economic Analysis … Principal Investigator Levy, Douglas Project Name Economic Analysis of an Information

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/856584/psn-pdf
    January 01, 2024 - Patient safety incidents in endoscopy: a human factors analysis of non-procedural significant harm incidents … Patient safety incidents in endoscopy: a human factors analysis of nonprocedural significant harm incidents … https://psnet.ahrq.gov/issue/patient-safety-incidents-endoscopy-human-factors-analysis-non-procedural … Based on Human Factors Analysis and Classification System coding, decision-based errors were the most … https://psnet.ahrq.gov/issue/human-factors-analysis-classification-system-hfacs-applied-health-care

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/859350/psn-pdf
    December 20, 2023 - What are the experiences of team members involved in root cause analysis? A qualitative study. … What are the experiences of team members involved in root cause analysis? A qualitative study. … https://psnet.ahrq.gov/issue/what-are-experiences-team-members-involved-root-cause-analysis-qualitative … https://psnet.ahrq.gov/primer/root-cause-analysis https://psnet.ahrq.gov/issue/our-current-approach-root-cause-analysis-it-contributing-our-failure-improve-patient-safety … https://psnet.ahrq.gov/perspective/rethinking-root-cause-analysis

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46606/psn-pdf
    July 10, 2019 - Implementation of a mock root cause analysis to provide simulated patient safety training. … Implementation of a mock root cause analysis to provide simulated patient safety training. … https://psnet.ahrq.gov/issue/implementation-mock-root-cause-analysis-provide-simulated-patient-safety … - training Root cause analysis is a strategy to identify and reduce risks, but there are concerns regarding … https://psnet.ahrq.gov/primer/root-cause-analysis https://psnet.ahrq.gov/issue/our-current-approach-root-cause-analysis-it-contributing-our-failure-improve-patient-safety

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/849317/psn-pdf
    May 24, 2023 - Implementing an electronic root cause analysis reporting system to decrease hospital-acquired pressure … Implementing an electronic root cause analysis reporting system to decrease hospital- acquired pressure … https://psnet.ahrq.gov/issue/implementing-electronic-root-cause-analysis-reporting-system-decrease- … A root cause analysis was completed for each HAPI to identify trends and implement improvements. … https://psnet.ahrq.gov/issue/root-cause-analysis-hospital-acquired-pressure-injury

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/862129/psn-pdf
    February 07, 2024 - Application of "Human Factor Analysis and Classification System" (HFACS) model to the prevention of … https://psnet.ahrq.gov/issue/application-human-factor-analysis-and-classification-system-hfacs-model- … prevention-medical Human Factor Analysis and Classification System (HFACS) in healthcare is used to … This review found 12 studies that used HFACS for coding, cause analysis, and categorization of adverse … https://psnet.ahrq.gov/issue/human-factors-analysis-classification-system-hfacs-applied-health-care

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837200/psn-pdf
    May 25, 2022 - Analysis of readmissions in a mobile integrated health transitional care program using root cause analysis … and common cause analysis. … Analysis of readmissions in a mobile integrated health transitional care program using root cause analysis … and common cause analysis. … https://psnet.ahrq.gov/issue/analysis-readmissions-mobile-integrated-health-transitional-care-program

  12. An observational study of how patients are identified before medication administrations in medical and surgical wards. | PSNet

    psnet.ahrq.gov/issue/observational-study-how-patients-are-identified-medication-administrations-medical-and
    June 24, 2020 - June 24, 2020 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.

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73462/psn-pdf
    July 07, 2021 - Root cause analysis to identify contributing factors for the development of hospital acquired pressure … Root cause analysis to identify contributing factors for the development of hospital acquired pressure … https://psnet.ahrq.gov/issue/root-cause-analysis-identify-contributing-factors-development-hospital- … Through root cause analysis, this geriatric rehabilitation hospital identified factors that contributed … /primer/root-cause-analysis https://psnet.ahrq.gov/primer/root-cause-analysis https://psnet.ahrq.gov/

  14. Toh, Darren | Digital Healthcare Research

    digital.ahrq.gov/principal-investigator/toh-darren
    January 01, 2023 - Toh, Darren Combining meta-analysis with multiple imputation for one-step … Combining meta-analysis with multiple imputation for one-step, privacy-protecting estimation of causal … Research Networks Imputing missing covariates in time-to-event analysis within … Imputing missing covariates in time-to-event analysis within distributed research networks: A simulation … Improving Missing Data Analysis in Distributed Research Networks - Final Report.

  15. Risk Assessment | Digital Healthcare Research

    digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/risk
    January 01, 2023 - Event Tree Analysis Description An event tree analysis (ETA) examines the different paths that … Failure Mode and Effects Analysis Description Failure mode and effects analysis (FMEA) is a … Fault Tree Analysis Description Fault tree analyses (FTAs) study specific system, process, … Potential Problem Analysis Description A potential problem analysis (PPA) is a systematic method … Root Cause Analysis Description Root cause analysis (RCA) is a popular technique used to determine

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/856590/psn-pdf
    November 29, 2023 - Team experiences of the root cause analysis process after a sentinel event: a qualitative case study … Team experiences of the root cause analysis process after a sentinel event: a qualitative case study … https://psnet.ahrq.gov/issue/team-experiences-root-cause-analysis-process-after-sentinel-event-qualitative … - case-study Root cause analysis (RCA) is a frequently used, and sometimes mandatory, method to investigate … https://psnet.ahrq.gov/perspective/rethinking-root-cause-analysis https://psnet.ahrq.gov/issue/root-cause-analysis-health-care-joint-commission-guide-analysis-and-corrective-action

  17. Process Improvement | Digital Healthcare Research

    digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/process
    January 01, 2023 - Value-Added Analysis Description Value-added analysis is a method for identifying problems … Cost-of-Poor-Quality Analysis Description A cost-of-poor-quality analysis evaluates the flowchart … The level of granularity will vary based on the needs of the analysis. … Groupware Task Analysis Description Groupware task analysis (GTA) is used to study teams in … Hierarchical Task Analysis Description A hierarchical task analysis (HTA) describes an activity

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/764390/psn-pdf
    March 02, 2022 - Does root cause analysis improve patient safety? … Does root cause analysis improve patient safety? … Root cause analysis (RCA) is a tool commonly used by organizations to analyze safety errors. … https://psnet.ahrq.gov/primer/root-cause-analysis https://psnet.ahrq.gov/issue/cross-sectional-study-relationship-between-utilization-root-cause-analysis-and-patient-safety … https://psnet.ahrq.gov/perspective/rethinking-root-cause-analysis

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72546/psn-pdf
    December 09, 2020 - Analysis of incidents resulting in patient injuries in a web-based system in Swedish health care. … Analysis of incidents resulting in patient injuries in a web-based system in Swedish health care. … https://psnet.ahrq.gov/issue/learning-incident-reporting-analysis-incidents-resulting-patient-injuries-web … This analysis of incident reports occurring at one hospital in Sweden found that the handling, causes … https://psnet.ahrq.gov/primer/reporting-patient-safety-events https://psnet.ahrq.gov/primer/root-cause-analysis

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60350/psn-pdf
    May 20, 2020 - Apparent cause analysis: a safety tool. May 20, 2020 Parikh K, Hochberg E, Cheng JJ, et al. … Apparent cause analysis: a safety tool. … https://psnet.ahrq.gov/issue/apparent-cause-analysis-safety-tool This article explores one hospital’ … s use of facilitated apparent cause analysis  (ACA), which is defined as a limited investigation of … https://psnet.ahrq.gov/issue/apparent-cause-analysis-safety-tool https://psnet.ahrq.gov/primer/root-cause-analysis
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