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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43207/psn-pdf
    April 25, 2016 - Root cause analysis of serious adverse events among older patients in the Veterans Health Administration … Root cause analysis of serious adverse events among older patients in the Veterans Health Administration … https://psnet.ahrq.gov/issue/root-cause-analysis-serious-adverse-events-among-older-patients-veterans … Compared to previous research, this study highlights robust use of root cause analysis while emphasizing … https://psnet.ahrq.gov/issue/root-cause-analysis-serious-adverse-events-among-older-patients-veterans-health

  2. Gastric-Cancers-Supplementary-App-I (xls file)

    effectivehealthcare.ahrq.gov/sites/default/files/related_files/gastric-cancers-supplementary-app-i.xlsx
    January 01, 2019 - Analysis does not appear to adjust for multiplicity. … N/A N/A Very low credibility Evaluation of modification is a post-hoc analysis. … Analysis is specified as post-hoc. … Based on post-hoc analysis. … Analysis is specified as post-hoc.

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35435/psn-pdf
    June 14, 2011 - Drill down with root cause analysis. June 14, 2011 McDonald A, Leyhane T. … Drill down with root cause analysis. Nurs Manage. 2005;36(10):26-32. … https://psnet.ahrq.gov/issue/drill-down-root-cause-analysis The authors outline a six-step process for … root cause analysis and highlight the importance of understanding state disclosure and discovery laws … https://psnet.ahrq.gov/issue/drill-down-root-cause-analysis https://psnet.ahrq.gov/primer/root-cause-analysis

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38383/psn-pdf
    June 30, 2011 - A system analysis of a suboptimal surgical experience. … A system analysis of a suboptimal surgical experience. … https://psnet.ahrq.gov/issue/system-analysis-suboptimal-surgical-experience A post-surgical complication … https://psnet.ahrq.gov/issue/system-analysis-suboptimal-surgical-experience https://psnet.ahrq.gov/primer … /root-cause-analysis

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40898/psn-pdf
    February 06, 2012 - Creating a web-based incident analysis and communication system. … Creating a web-based incident analysis and communication system. … https://psnet.ahrq.gov/issue/creating-web-based-incident-analysis-and-communication-system This study … reports on the development of a system for standardizing root cause analysis of sentinel events. … /primer/root-cause-analysis https://psnet.ahrq.gov/primer/never-events

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41508/psn-pdf
    July 11, 2012 - Complications in surgery: root cause analysis and preventive measures. … Complications in surgery: root cause analysis and preventive measures. … https://psnet.ahrq.gov/issue/complications-surgery-root-cause-analysis-and-preventive-measures This … https://psnet.ahrq.gov/issue/complications-surgery-root-cause-analysis-and-preventive-measures https: … //psnet.ahrq.gov/primer/root-cause-analysis

  7. Wrong drug and wrong dose dispensing errors identified in pharmacist professional liability claims. | PSNet

    psnet.ahrq.gov/issue/wrong-drug-and-wrong-dose-dispensing-errors-identified-pharmacist-professional-liability
    August 31, 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.

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42590/psn-pdf
    August 02, 2015 - Health care-associated infections: a meta-analysis of costs and financial impact on the US health care … Health care-associated infections: a meta-analysis of costs and financial impact on the US health care … https://psnet.ahrq.gov/issue/health-care-associated-infections-meta-analysis-costs-and-financial-impact-us … This economic analysis combined a systematic review of estimates of costs attributable to HAIs with … https://psnet.ahrq.gov/issue/business-case-quality-case-studies-and-analysis

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44754/psn-pdf
    March 23, 2016 - Use of failure mode and effects analysis to improve emergency department handoff processes. … Use of Failure Mode and Effects Analysis to Improve Emergency Department Handoff Processes. … https://psnet.ahrq.gov/issue/use-failure-mode-and-effects-analysis-improve-emergency-department- handoff-processes … This commentary describes a project that used failure mode and effects analysis to identify weaknesses … https://psnet.ahrq.gov/issue/use-failure-mode-and-effects-analysis-improve-emergency-department-handoff-processes

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46188/psn-pdf
    June 21, 2017 - Death by suicide within 1 week of hospital discharge: a retrospective study of root cause analysis reports … Death by Suicide Within 1 Week of Hospital Discharge: A Retrospective Study of Root Cause Analysis Reports … psnet.ahrq.gov/issue/death-suicide-within-1-week-hospital-discharge-retrospective-study-root- cause-analysis … This review of root cause analysis reports about suicide within 7 days of discharge from inpatient … /psnet.ahrq.gov/issue/death-suicide-within-1-week-hospital-discharge-retrospective-study-root-cause-analysis

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43595/psn-pdf
    November 19, 2014 - Patient safety in external beam radiotherapy—guidelines on risk assessment and analysis of adverse error-events … Patient safety in external beam radiotherapy - guidelines on risk assessment and analysis of adverse … https://psnet.ahrq.gov/issue/patient-safety-external-beam-radiotherapy-guidelines-risk-assessment-and- analysis-adverse … other safety concerns, adverse events are under-reported to voluntary reporting systems and root cause analysis … https://psnet.ahrq.gov/primer/reporting-patient-safety-events https://psnet.ahrq.gov/primer/root-cause-analysis

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37784/psn-pdf
    May 27, 2011 - A risk analysis method to evaluate the impact of a Computerized Provider Order Entry system on patient … A risk analysis method to evaluate the impact of a computerized provider order entry system on patient … https://psnet.ahrq.gov/issue/risk-analysis-method-evaluate-impact-computerized-provider-order-entry- … This study conducted a detailed quantitative analysis, following a failure mode and effect analysis … https://psnet.ahrq.gov/issue/risk-analysis-method-evaluate-impact-computerized-provider-order-entry-system-patient-safety

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39520/psn-pdf
    June 10, 2018 - Building patient safety skills: common pitfalls when conducting a root cause analysis. … ://psnet.ahrq.gov/issue/building-patient-safety-skills-common-pitfalls-when-conducting-root-cause- analysis … This piece highlights common failures in root cause analysis (RCA) and explains how each undermines … https://psnet.ahrq.gov/issue/building-patient-safety-skills-common-pitfalls-when-conducting-root-cause-analysis … https://psnet.ahrq.gov/primer/root-cause-analysis

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41673/psn-pdf
    September 12, 2012 - A root cause analysis project in a medication safety course. September 12, 2012 Schafer JJ. … A root cause analysis project in a medication safety course. … an initiative to integrate development of root cause analysis skills into a pharmacy curriculum to … https://psnet.ahrq.gov/issue/root-cause-analysis-project-medication-safety-course https://psnet.ahrq.gov … /primer/root-cause-analysis https://psnet.ahrq.gov/issue/educating-safety

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41592/psn-pdf
    August 15, 2012 - Failure mode and effects analysis outputs: are they valid? … Failure mode and effects analysis outputs: are they valid? … https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-outputs-are-they-valid This study casts … doubt on the validity and reliability of failure mode and effect analysis, a commonly used tool to … /issue/healthcare-failure-mode-and-effect-analysis

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40106/psn-pdf
    December 22, 2010 - Root cause analysis of transfusion error: identifying causes to implement changes. … Root cause analysis of transfusion error: identifying causes to implement changes. … https://psnet.ahrq.gov/issue/root-cause-analysis-transfusion-error-identifying-causes-implement-changes … This case review discusses how root cause analysis of human and systems failures can identify areas … https://psnet.ahrq.gov/primer/root-cause-analysis

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44917/psn-pdf
    November 30, 2016 - Canadian Incident Analysis Framework. November 30, 2016 Incident Analysis Collaborating Parties. … https://psnet.ahrq.gov/issue/canadian-incident-analysis-framework Performing incident analysis can help … https://psnet.ahrq.gov/issue/canadian-incident-analysis-framework https://psnet.ahrq.gov/primer/root-cause-analysis

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41893/psn-pdf
    January 09, 2013 - Counting matters: lessons from the root cause analysis of a retained surgical item. … Counting matters: lessons from the root cause analysis of a retained surgical item. … https://psnet.ahrq.gov/issue/counting-matters-lessons-root-cause-analysis-retained-surgical-item Reporting … root cause analysis results from a retained surgical item case, this commentary identifies contributing … https://psnet.ahrq.gov/issue/counting-matters-lessons-root-cause-analysis-retained-surgical-item https

  19. 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

  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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