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  1. 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

  2. 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

  3. 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.

  4. 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

  5. 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

  6. 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.

  7. 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

  8. 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

  9. 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

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36868/psn-pdf
    August 29, 2011 - Quali-quantitative analysis: a new model for evaluation of unusual cases in hospital performance? … Quali-quantitative analysis: a new model for evaluation of unusual cases in hospital performance? … https://psnet.ahrq.gov/issue/quali-quantitative-analysis-new-model-evaluation-unusual-cases-hospital- … criteria of high-quality hospital error research and explores the potential of quali-quantitative analysis … https://psnet.ahrq.gov/issue/quali-quantitative-analysis-new-model-evaluation-unusual-cases-hospital-performance

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37095/psn-pdf
    September 04, 2010 - Prospective error recording in surgery: an analysis of 1108 elective neurosurgical cases. … Prospective error recording in surgery: an analysis of 1108 elective neurosurgical cases. … https://psnet.ahrq.gov/issue/prospective-error-recording-surgery-analysis-1108-elective-neurosurgical … - cases This analysis of cases performed by a single neurosurgeon found that errors occurred frequently … https://psnet.ahrq.gov/issue/prospective-error-recording-surgery-analysis-1108-elective-neurosurgical-cases

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42236/psn-pdf
    May 01, 2013 - Nursing student medication errors: a case study using root cause analysis. … Nursing student medication errors: a case study using root cause analysis. … https://psnet.ahrq.gov/issue/nursing-student-medication-errors-case-study-using-root-cause-analysis … This commentary examines a medication error involving insulin using root case analysis to identify factors … https://psnet.ahrq.gov/issue/nursing-student-medication-errors-case-study-using-root-cause-analysis https

  13. 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

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39091/psn-pdf
    June 28, 2011 - Integration of prospective and retrospective methods for risk analysis in hospitals. … Integration of prospective and retrospective methods for risk analysis in hospitals. … https://psnet.ahrq.gov/issue/integration-prospective-and-retrospective-methods-risk-analysis-hospitals … https://psnet.ahrq.gov/issue/integration-prospective-and-retrospective-methods-risk-analysis-hospitals … https://psnet.ahrq.gov/primer/root-cause-analysis

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44909/psn-pdf
    March 23, 2016 - Root Cause Analysis Workbook for Community/Ambulatory Pharmacy. … https://psnet.ahrq.gov/issue/root-cause-analysis-workbook-communityambulatory-pharmacy Root cause analysis … This workbook illustrates how root cause analysis can be applied to community pharmacy services to identify … https://psnet.ahrq.gov/issue/root-cause-analysis-workbook-communityambulatory-pharmacy https://psnet.ahrq.gov … /primer/root-cause-analysis https://psnet.ahrq.gov/issue/dispensing-errors-community-pharmacy-perceived-influence-sociotechnical-factors

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40004/psn-pdf
    February 01, 2011 - Application of failure mode and effect analysis in a radiology department. … Application of Failure Mode and Effect Analysis in a Radiology Department. … https://psnet.ahrq.gov/issue/application-failure-mode-and-effect-analysis-radiology-department This … commentary introduces the failure mode and effects analysis process developed by the United States Department … https://psnet.ahrq.gov/issue/application-failure-mode-and-effect-analysis-radiology-department https:

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36800/psn-pdf
    August 26, 2011 - Application of the human factors analysis and classification system methodology to the cardiovascular … Application of the human factors analysis and classification system methodology to the cardiovascular … https://psnet.ahrq.gov/issue/application-human-factors-analysis-and-classification-system-methodology … - cardiovascular The authors adapted an incident analysis model used in aviation to understand the … https://psnet.ahrq.gov/issue/application-human-factors-analysis-and-classification-system-methodology-cardiovascular

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35322/psn-pdf
    July 14, 2009 - Safe chemotherapy administration: using failure mode and effects analysis in computerized prescriber … Safe chemotherapy administration: Using failure mode and effects analysis in computerized prescriber … https://psnet.ahrq.gov/issue/safe-chemotherapy-administration-using-failure-mode-and-effects-analysis … - computerized This case study describes one hospital’s use of failure mode and effects analysis (FMEA … https://psnet.ahrq.gov/issue/safe-chemotherapy-administration-using-failure-mode-and-effects-analysis-computerized

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39865/psn-pdf
    May 28, 2014 - Failure Mode and Effects Analysis in Health Care: Proactive Risk Reduction, Third Edition. … https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-health-care-proactive-risk-reduction-third … edition This publication provides strategies for organizations to utilize the Failure Mode and Effects Analysis … https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-health-care-proactive-risk-reduction-third-edition … https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-health-care-proactive-risk-reduction-third-edition

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43795/psn-pdf
    December 17, 2014 - Systematic Systems Analysis: A Practical Approach to Patient Safety Reviews. … https://psnet.ahrq.gov/issue/systematic-systems-analysis-practical-approach-patient-safety-reviews Drawing … from human factors and system analysis techniques, this guide describes an approach to identifying … https://psnet.ahrq.gov/issue/systematic-systems-analysis-practical-approach-patient-safety-reviews https … https://psnet.ahrq.gov/issue/cross-sectional-analysis-investigating-organizational-factors-influence-near-miss-error
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