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  1. Interventions to reduce medication dispensing, administration, and monitoring errors in pediatric professional healthcare settings: a systematic review. | PSNet

    psnet.ahrq.gov/issue/interventions-reduce-medication-dispensing-administration-and-monitoring-errors-pediatric
    June 23, 2021 - July 22, 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.

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48076/psn-pdf
    July 24, 2019 - Simulation-based event analysis improves error discovery and generates improved strategies for error … Simulation-based event analysis improves error discovery and generates improved strategies for error … https://psnet.ahrq.gov/issue/simulation-based-event-analysis-improves-error-discovery-and-generates- … improved-strategies Root cause analysis (RCA) is a vital tool to assess errors and prevent their recurrence … https://psnet.ahrq.gov/issue/effectiveness-and-efficiency-root-cause-analysis-medicine

  3. Proceedings of a summit on preventing patient harm and death from IV medication errors. | PSNet

    psnet.ahrq.gov/issue/proceedings-summit-preventing-patient-harm-and-death-iv-medication-errors
    June 16, 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.

  4. Patient engagement in health care safety: an overview of mixed-quality evidence. | PSNet

    psnet.ahrq.gov/issue/patient-engagement-health-care-safety-overview-mixed-quality-evidence
    October 21, 2020 - Analysis of incident reports from a patient safety organization. … 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. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848360/psn-pdf
    May 03, 2023 - Optimizing measurement of misdiagnosis-related harms using symptom-disease pair analysis of diagnostic … Optimizing measurement of misdiagnosis-related harms using symptom-disease pair analysis of diagnostic … psnet.ahrq.gov/issue/optimizing-measurement-misdiagnosis-related-harms-using-symptom-disease- pair-analysis … Symptom–Disease Pair Analysis of Diagnostic Error (SPADE) is a framework to measure diagnostic errors … comparator groups, how to select the appropriate group, and what inferences can be drawn from the analysis

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/61031/psn-pdf
    October 14, 2020 - Special Section: Event Analysis and Risk Management. October 14, 2020 Alemi F ed. … https://psnet.ahrq.gov/issue/special-section-event-analysis-and-risk-management Adverse event analysis … This special section discusses how examination tools such as failure mode and effect analysis and root … cause analysis may be amended to optimize how lessons can be drawn from failure to inform improvement … https://psnet.ahrq.gov/issue/special-section-event-analysis-and-risk-management https://psnet.ahrq.gov

  7. Lack of standard dosing methods contributes to IV errors. | PSNet

    psnet.ahrq.gov/issue/lack-standard-dosing-methods-contributes-iv-errors
    December 07, 2022 - 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. Partial Breast Irradiation for Breast Cancer: Systematic Review Protocol (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/product/pdf/pbi-protocol.pdf
    August 09, 2021 - " or "field analysis" or "in vivo study" or "in vivo analysis" or "panel study" or "panel survey" or … analysis " or "replication trial" or "theoretical study" or "theoretical analysis " or "feasibility … " or "field analysis" or "in vivo study" or "in vivo analysis" or "panel study" or "panel survey" or … "feasibility analysis" or "trend study" or "trend survey" or "trend analysis" or ((correlation* W/2 … ” or “field analysis” or “in vivo study” or “in vivo analysis” or “panel study” or “panel survey” or

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74099/psn-pdf
    January 01, 2022 - Hemodialysis bleeding events and deaths: an 18-year retrospective analysis of patient safety and root … cause analysis reports in the Veterans Health Administration. … Hemodialysis bleeding events and deaths: an 18-year retrospective analysis of patient safety and root … cause analysis reports in the Veterans Health Administration. … https://psnet.ahrq.gov/issue/hemodialysis-bleeding-events-and-deaths-18-year-retrospective-analysis-

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/845637/psn-pdf
    March 08, 2023 - Using Failure Mode, Effect and Criticality Analysis to improve safety in the cancer treatment prescription … Using Failure Mode, Effect and Criticality Analysis to improve safety in the cancer treatment prescription … https://psnet.ahrq.gov/issue/using-failure-mode-effect-and-criticality-analysis-improve-safety-cancer … - treatment Failure Mode, Effect and Criticality Analysis (FMECA) is a prospective method for identifying … https://psnet.ahrq.gov/issue/using-failure-mode-effect-and-criticality-analysis-improve-safety-cancer-treatment

  11. Butler, Keith | Digital Healthcare Research

    digital.ahrq.gov/principal-investigator/butler-keith
    January 01, 2023 - Principal Investigator Butler, Keith Project Name Modeling and Analysis of Clinical Care … Principal Investigator Butler, Keith Project Name Modeling and Analysis of Clinical Care … for Health Information Technology Improvement Modeling and Analysis of Clinical … Modeling and Analysis of Clinical Care for Health Information Technology Improvement - Final Report. … Principal Investigator Butler, Keith Project Name Modeling and Analysis of Clinical Care

  12. Your attention please... designing effective warnings. | PSNet

    psnet.ahrq.gov/issue/your-attention-please-designing-effective-warnings
    March 14, 2023 - 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.

  13. The safety of intravenous drug delivery systems: update on current issues since the 1999 Consensus Development Conference. | PSNet

    psnet.ahrq.gov/issue/safety-intravenous-drug-delivery-systems-update-current-issues-1999-consensus-development
    May 13, 2020 - 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.

  14. Pharmacy mixes up prescriptions. | PSNet

    psnet.ahrq.gov/issue/pharmacy-mixes-prescriptions
    March 10, 2021 - 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. Infusion medication error reduction by two-person verification: a quality improvement initiative. | PSNet

    psnet.ahrq.gov/issue/infusion-medication-error-reduction-two-person-verification-quality-improvement-initiative
    June 19, 2019 - July 10, 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.

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836812/psn-pdf
    March 30, 2022 - Tools covered in this primer include incident reporting systems, Root Cause Analysis (RCA), and Failure … Modes and Effects Analysis (FMEA). … Example Root Cause Analysis https://psnet.ahrq.gov/issue/wrong-site-and-wrong-patient-procedures-universal-protocol-era-analysis-prospective-database … Failure modes and effects analysis (FMEA) is a structured adverse event analysis tool that aims to … Root Cause Analysis: The Core of Problem Solving and Corrective Action, Second Edition.

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60932/psn-pdf
    January 01, 2021 - Retrospective analysis of reported suicide deaths and attempts on Veterans Health Administration campuses … Retrospective analysis of reported suicide deaths and attempts on Veterans Health Administration campuses … https://psnet.ahrq.gov/issue/retrospective-analysis-reported-suicide-deaths-and-attempts-veterans-health … - administration This retrospective analysis used root cause analysis reports of suicide events in … https://psnet.ahrq.gov/issue/retrospective-analysis-reported-suicide-deaths-and-attempts-veterans-health-administration

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851199/psn-pdf
    July 05, 2023 - Understanding the root cause analysis process to increase safety event reporting. … Understanding the root cause analysis process to increase safety event reporting. … https://psnet.ahrq.gov/issue/understanding-root-cause-analysis-process-increase-safety-event-reporting … Root cause analysis (RCA) may not be an ideal process, but it still creates opportunities for learning … https://psnet.ahrq.gov/primer/root-cause-analysis https://psnet.ahrq.gov/perspective/rethinking-root-cause-analysis

  19. Incidence of drug-related adverse events related to the use of high-alert drugs: a systematic review of randomized controlled trials. | PSNet

    psnet.ahrq.gov/issue/incidence-drug-related-adverse-events-related-use-high-alert-drugs-systematic-review
    May 20, 2020 - 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.

  20. Opioids, iatrogenic harm and disclosure of medical error. | PSNet

    psnet.ahrq.gov/issue/opioids-iatrogenic-harm-and-disclosure-medical-error
    November 21, 2021 - 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.
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