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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837694/psn-pdf
    July 20, 2022 - Implementing root cause analysis and action: integrating human factors to create strong interventions … Implementing root cause analysis and action: integrating human factors to create strong interventions … https://psnet.ahrq.gov/issue/implementing-root-cause-analysis-and-action-integrating-human-factors- … This study found that integrating human factors into a new root cause analysis process led to an increase … https://psnet.ahrq.gov/issue/implementing-root-cause-analysis-and-action-integrating-human-factors-create-strong

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60575/psn-pdf
    June 10, 2020 - Applying principles from aviation safety investigations to root cause analysis of a critical incident … Applying principles from aviation safety investigations to root cause analysis of a critical incident … https://psnet.ahrq.gov/issue/applying-principles-aviation-safety-investigations-root-cause-analysis-critical … - incident This case study describes the use of root cause analysis to investigate a critical incident … https://psnet.ahrq.gov/issue/applying-principles-aviation-safety-investigations-root-cause-analysis-critical-incident

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50938/psn-pdf
    February 26, 2020 - Risks and medication errors analysis to evaluate the impact of a chemotherapy compounding workflow … Risks and medication errors analysis to evaluate the impact of a chemotherapy compounding workflow management … https://psnet.ahrq.gov/issue/risks-and-medication-errors-analysis-evaluate-impact-chemotherapy- compounding-workflow … This study applied failure mode, effect, and criticality analysis (FMECA) methodology to identify the … https://psnet.ahrq.gov/issue/risks-and-medication-errors-analysis-evaluate-impact-chemotherapy-compounding-workflow

  4. Examining causes and prevention strategies of adverse events in deceased hospital patients: a retrospective patient record review study in the Netherlands. | PSNet

    psnet.ahrq.gov/issue/examining-causes-and-prevention-strategies-adverse-events-deceased-hospital-patients
    June 08, 2022 - using the prevention and recovery information system for monitoring and analysis method in healthcare … April 7, 2021 Evolving factors in hospital safety: a systematic review and meta-analysis … October 6, 2021 A systematic review of methods for medical record analysis to detect … June 29, 2022 Hemodialysis bleeding events and deaths: an 18-year retrospective analysis … of patient safety and root cause analysis reports in the Veterans Health Administration.

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837668/psn-pdf
    July 13, 2022 - Factors associated with malpractice claim payout: an analysis of closed emergency department claims. … Factors associated with malpractice claim payout: an analysis of closed emergency department claims. … https://psnet.ahrq.gov/issue/factors-associated-malpractice-claim-payout-analysis-closed-emergency- … department-claims Analysis of closed malpractice claims can be used to identify potential safety hazards … This analysis of closed emergency department malpractice claims indicates that diagnostic errors dominate

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73485/psn-pdf
    July 14, 2021 - The RCA ReCAst: a root cause analysis simulation for the interprofessional clinical learning environment … The RCA ReCAst: a root cause analysis simulation for the interprofessional clinical learning environment … https://psnet.ahrq.gov/issue/rca-recast-root-cause-analysis-simulation-interprofessional-clinical-learning … - environment Root cause analysis (RCA) is a common method to investigate adverse events and identify … https://psnet.ahrq.gov/issue/rca-recast-root-cause-analysis-simulation-interprofessional-clinical-learning-environment

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73473/psn-pdf
    January 01, 2022 - Improving safety recommendations before implementation: a simulation-based event analysis to optimize … Improving safety recommendations before implementation: a simulation-based event analysis to optimize … https://psnet.ahrq.gov/issue/improving-safety-recommendations-implementation-simulation-based-event- analysis-optimize … Prior research has found that simulation-based event analysis (SBEA) can identify novel sources of … https://psnet.ahrq.gov/issue/improving-safety-recommendations-implementation-simulation-based-event-analysis-optimize

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74084/psn-pdf
    November 17, 2021 - Healthcare failure mode and effect analysis in the chemotherapy preparation process. … Healthcare failure mode and effect analysis in the chemotherapy preparation process. … https://psnet.ahrq.gov/issue/healthcare-failure-mode-and-effect-analysis-chemotherapy-preparation- process … Researchers in this study used healthcare failure mode and effect analysis (HFMEA) to identify and … https://psnet.ahrq.gov/issue/healthcare-failure-mode-and-effect-analysis https://psnet.ahrq.gov/issue

  9. Adverse drug events in hospitalized cardiac patients. | PSNet

    psnet.ahrq.gov/issue/adverse-drug-events-hospitalized-cardiac-patients
    July 26, 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.

  10. ISMP survey on tall man (mixed case) lettering to reduce drug name confusion. | PSNet

    psnet.ahrq.gov/issue/ismp-survey-tall-man-mixed-case-lettering-reduce-drug-name-confusion
    January 26, 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.

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73258/psn-pdf
    May 12, 2021 - sepsis hospitalizations after misdiagnosis in adult emergency department patients: a look-forward analysis … with administrative claims data using Symptom-Disease Pair Analysis of Diagnostic Error methodology … sepsis hospitalizations after misdiagnosis in adult emergency department patients: a look-forward analysis … with administrative claims data using Symptom- Disease Pair Analysis of Diagnostic Error methodology … This study used a Symptom- Disease Pair Analysis of Diagnostic Error (SPADE) “look-forward” analysis

  12. Quantitative Synthesis: Chapter 4. Quantifying, Testing, and Exploring Statistical Heterogeneity (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/pdf/ehc-presentation-quantitative-synthesis-chapter-4.pdf
    July 01, 2019 - A meta-analysis. … Meta-analysis in clinical trials. … A meta-analysis. … Meta-analysis in clinical trials. … Meta-Analysis and Subgroups.

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851651/psn-pdf
    July 26, 2023 - Using failure mode and effect analysis to identify potential failures in a psychiatric hospital emergency … Using failure mode and effect analysis to identify potential failures in a psychiatric hospital emergency … https://psnet.ahrq.gov/issue/using-failure-mode-and-effect-analysis-identify-potential-failures-psychiatric … - hospital Failure mode and effect analysis (FMEA) is a common way to identify error risk. … https://psnet.ahrq.gov/issue/using-failure-mode-and-effect-analysis-identify-potential-failures-psychiatric-hospital

  14. Development and performance evaluation of the Medicines Optimisation Assessment Tool (MOAT): a prognostic model to target hospital pharmacists' input to prevent medication-related problems. | PSNet

    psnet.ahrq.gov/issue/development-and-performance-evaluation-medicines-optimisation-assessment-tool-moat-prognostic
    March 18, 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.

  15. AHRQ's Guide to Evaluating Health Information Exchange Projects - Appendix A - Workbook (pdf file)

    digital.ahrq.gov/sites/default/files/docs/page/guide-to-evaluating-hie-projects-appendix-a.pdf
    June 16, 2021 - Analysis: • For quantitative methods: What types of statistical analysis will you perform on your data … • Who will lead the data analysis? • Who will present the findings? … : Measure 2 - Analysis: Measure 3 - Analysis: Measure 4 - Analysis: Measure 1 - Statistical Analysis … : Measure 2 - Statistical Analysis: Measure 3 - Statistical Analysis: Measure 4 - Statistical Analysis … : Measure 2 - Lead for Data Analysis: Measure 3 - Lead for Data Analysis: Measure 4 - Lead for

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47096/psn-pdf
    November 14, 2018 - analysis system. … Analysis System. … - cause-analysis This analysis of the Veterans Health Administration root cause analysis database identified … https://psnet.ahrq.gov/issue/analysis-adverse-events-rehabilitation-department-using-veterans-affairs-root-cause-analysis … https://psnet.ahrq.gov/issue/analysis-adverse-events-rehabilitation-department-using-veterans-affairs-root-cause-analysis

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35721/psn-pdf
    March 28, 2011 - Health Care Failure Mode and Effect Analysis: a useful proactive risk analysis in a pediatric oncology … Health Care Failure Mode and Effect Analysis: a useful proactive risk analysis in a pediatric oncology … https://psnet.ahrq.gov/issue/health-care-failure-mode-and-effect-analysis-useful-proactive-risk-analysis … https://psnet.ahrq.gov/issue/health-care-failure-mode-and-effect-analysis-useful-proactive-risk-analysis-pediatric … https://psnet.ahrq.gov/issue/health-care-failure-mode-and-effect-analysis-useful-proactive-risk-analysis-pediatric

  18. Preparing your hospital for compliance with The Joint Commission's National Patient Safety Goals. | PSNet

    psnet.ahrq.gov/issue/preparing-your-hospital-compliance-joint-commissions-national-patient-safety-goals
    December 30, 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.

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39303/psn-pdf
    February 17, 2010 - Patient misidentification in laboratory medicine: a qualitative analysis of 227 root cause analysis … Patient misidentification in laboratory medicine: a qualitative analysis of 227 root cause analysis … https://psnet.ahrq.gov/issue/patient-misidentification-laboratory-medicine-qualitative-analysis-227-root … https://psnet.ahrq.gov/issue/patient-misidentification-laboratory-medicine-qualitative-analysis-227-root-cause-analysis … root-cause-analysis https://psnet.ahrq.gov/primer/root-cause-analysis

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43281/psn-pdf
    May 28, 2015 - A method for prioritizing interventions following root cause analysis (RCA): lessons from philosophy … A method for prioritizing interventions following root cause analysis (RCA): lessons from philosophy … https://psnet.ahrq.gov/issue/method-prioritizing-interventions-following-root-cause-analysis-rca-lessons … This commentary suggests a three-step approach for optimizing root cause analysis results to detect … https://psnet.ahrq.gov/primer/root-cause-analysis https://psnet.ahrq.gov/issue/effectiveness-and-efficiency-root-cause-analysis-medicine
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