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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44484/psn-pdf
    May 04, 2016 - Failure mode and effects analysis: a comparison of two common risk prioritisation methods. … Failure mode and effects analysis: a comparison of two common risk prioritisation methods. … https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-comparison-two-common-risk-prioritisation … - methods Failure mode and effect analysis (FMEA) is a human factors engineering method used to examine … Comparing a traditional resource-intensive FMEA with a simplified version, this analysis found that

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40623/psn-pdf
    July 20, 2011 - Policy and practice in the use of root cause analysis to investigate clinical adverse events: mind the … Policy and practice in the use of root cause analysis to investigate clinical adverse events: mind the … https://psnet.ahrq.gov/issue/policy-and-practice-use-root-cause-analysis-investigate-clinical-adverse … - events-mind-gap This study explores the tensions between the theory of root cause analysis and its … https://psnet.ahrq.gov/primer/root-cause-analysis https://psnet.ahrq.gov/issue/effectiveness-and-efficiency-root-cause-analysis-medicine

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46777/psn-pdf
    January 24, 2018 - Safety analysis over time: seven major changes to adverse event investigation. … Safety analysis over time: seven major changes to adverse event investigation. … https://psnet.ahrq.gov/issue/safety-analysis-over-time-seven-major-changes-adverse-event-investigation … In-depth review and analysis of adverse events can both inform and detract from progress in patient … This commentary suggests that the early event analysis approaches have not achieved their potential.

  4. Strengthen your resolve: no unlabeled containers anywhere, ever! | PSNet

    psnet.ahrq.gov/issue/strengthen-your-resolve-no-unlabeled-containers-anywhere-ever
    November 16, 2015 - 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.

  5. The health information infrastructure in America today . . . . (pdf file)

    hcup-us.ahrq.gov/datainnovations/clinicaldata/AHRQHCUP11182009CSullivanFinal.pdf
    November 01, 2009 - Agency for Health Care Administration Florida Center for Health Information and Policy Analysis HCUP … Inpatient Data Agency for Health Care Administration Florida Center for Health Information and Policy Analysis … the data 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 … Agency for Health Care Administration Florida Center for Health Information and Policy Analysis Lab

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38303/psn-pdf
    December 17, 2008 - Errors and analysis of errors. December 17, 2008 Mulligan MA, Nechodom P. … Errors and analysis of errors. Clin Obstet Gynecol. 2008;51(4):656-65. … error reduction program and provides background on those strategies, including root cause analysis, … failure mode and effects analysis (FMEA), and human factors. … https://psnet.ahrq.gov/issue/errors-and-analysis-errors https://psnet.ahrq.gov/primer/root-cause-analysis

  7. Action needed to prevent dangerous heparin-insulin confusion. | PSNet

    psnet.ahrq.gov/issue/action-needed-prevent-dangerous-heparin-insulin-confusion
    May 07, 2018 - 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. Sterile water should not be given "freely." | PSNet

    psnet.ahrq.gov/issue/sterile-water-should-not-be-given-freely
    March 18, 2010 - 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.

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44773/psn-pdf
    January 13, 2016 - A tool for the concise analysis of patient safety incidents. … A Tool for the Concise Analysis of Patient Safety Incidents. … https://psnet.ahrq.gov/issue/tool-concise-analysis-patient-safety-incidents Once identified, adverse … investigation frameworks including the Canadian Incident Analysis Framework and the WHO High 5s program … https://psnet.ahrq.gov/issue/tool-concise-analysis-patient-safety-incidents https://psnet.ahrq.gov/primer

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45510/psn-pdf
    October 19, 2016 - How to perform a root cause analysis for workup and future prevention of medical errors: a review. … How to perform a root cause analysis for workup and future prevention of medical errors: a review. … https://psnet.ahrq.gov/issue/how-perform-root-cause-analysis-workup-and-future-prevention-medical- errors-review … Root cause analysis is a widely used strategy for understanding failure in patient care. … https://psnet.ahrq.gov/primer/root-cause-analysis https://psnet.ahrq.gov/primer/detection-safety-hazards

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37872/psn-pdf
    January 11, 2017 - The effectiveness of root cause analysis: what does the literature tell us? … The effectiveness of root cause analysis: what does the literature tell us? … https://psnet.ahrq.gov/issue/effectiveness-root-cause-analysis-what-does-literature-tell-us This review … analyzes whether the available research on root cause analysis (RCA) substantiates its effectiveness … /primer/root-cause-analysis https://psnet.ahrq.gov/issue/effectiveness-and-efficiency-root-cause-analysis-medicine

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41941/psn-pdf
    February 11, 2013 - A cross-sectional study on the relationship between utilization of root cause analysis and patient safety … A cross-sectional study on the relationship between utilization of root cause analysis and patient safety … https://psnet.ahrq.gov/issue/cross-sectional-study-relationship-between-utilization-root-cause-analysis-and … - patient-safety Root cause analysis (RCA) has been a Joint Commission mandated tool for examining … https://psnet.ahrq.gov/primer/root-cause-analysis https://psnet.ahrq.gov/issue/sentinel-event https:

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38655/psn-pdf
    November 25, 2009 - Is failure mode and effect analysis reliable? November 25, 2009 Shebl NA, Franklin BD, Barber N. … Is failure mode and effect analysis reliable? … https://psnet.ahrq.gov/issue/failure-mode-and-effect-analysis-reliable Failure mode and effect analysis … (FMEA) is a widely used tool for hazard analysis. … https://psnet.ahrq.gov/issue/failure-mode-and-effect-analysis-reliable https://psnet.ahrq.gov/issue/using-health-care-failure-mode-and-effect-analysis-va-national-center-patient-safetys

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41297/psn-pdf
    September 19, 2012 - Failure mode and effects analysis: too little for too much? … Failure mode and effects analysis: too little for too much? … the benefits and drawbacks of using failure mode and effects analysis as a prospective risk assessment … https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-too-little-too-much https://psnet.ahrq.gov … /issue/failure-mode-and-effect-analysis-reliable https://psnet.ahrq.gov/issue/using-health-care-failure-mode-and-effect-analysis-va-national-center-patient-safetys

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39537/psn-pdf
    October 01, 2013 - Conducting root cause analysis with nursing students: best practice in nursing education. … Conducting root cause analysis with nursing students: best practice in nursing education. … https://psnet.ahrq.gov/issue/conducting-root-cause-analysis-nursing-students-best-practice-nursing- … education This commentary describes the use of root cause analysis to engage nursing students in identifying … https://psnet.ahrq.gov/primer/root-cause-analysis

  16. 2009 National Patient Safety Goals. | PSNet

    psnet.ahrq.gov/issue/2009-national-patient-safety-goals
    August 03, 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.

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35479/psn-pdf
    June 14, 2011 - Implementing root cause analysis in an area health service: views of the participants. … Implementing root cause analysis in an area health service: views of the participants. … https://psnet.ahrq.gov/issue/implementing-root-cause-analysis-area-health-service-views-participants … https://psnet.ahrq.gov/issue/implementing-root-cause-analysis-area-health-service-views-participants … https://psnet.ahrq.gov/primer/root-cause-analysis https://psnet.ahrq.gov/primer/root-cause-analysis

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40060/psn-pdf
    December 15, 2010 - Failure mode and effects analysis: an empirical comparison of failure mode scoring procedures. … Failure Mode and Effects Analysis. J Patient Saf. 2010;6(4):210-215. … https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-empirical-comparison-failure-mode-scoring … - procedures This study empirically demonstrated that different failure mode effect analysis (FMEA) … https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-empirical-comparison-failure-mode-scoring-procedures

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40068/psn-pdf
    January 19, 2011 - Application of root cause analysis on malpractice claim files related to diagnostic failures. … Application of root cause analysis on malpractice claim files related to diagnostic failures. … https://psnet.ahrq.gov/issue/application-root-cause-analysis-malpractice-claim-files-related-diagnostic … - failures This study applied root cause analysis to cases of diagnostic failure, and discusses the … https://psnet.ahrq.gov/primer/root-cause-analysis https://psnet.ahrq.gov/primer/diagnostic-errors

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44025/psn-pdf
    February 22, 2018 - The causes of their death appear (unto our shame perpetual): why root cause analysis is not the best … The Causes of Their Death Appear (Unto Our Shame Perpetual): Why Root Cause Analysis Is Not the Best … https://psnet.ahrq.gov/issue/causes-their-death-appear-unto-our-shame-perpetual-why-root-cause- analysis-not-best-model … Root cause analysis is a longstanding approach to in-depth investigation of adverse events, with evidence … method may not be helpful, their findings also emphasize the importance of implementing root cause analysis
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