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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44089/psn-pdf
    April 22, 2015 - Learning from mistakes and near mistakes: using root cause analysis as a risk management tool. … Learning From Mistakes and Near Mistakes: Using Root Cause Analysis as a Risk Management Tool. … https://psnet.ahrq.gov/issue/learning-mistakes-and-near-mistakes-using-root-cause-analysis-risk- management-tool … Root cause analysis has been promoted by The Joint Commission and other organizations as a failure … analysis tool, though problems with its usefulness remain due to issues with implementation and sufficient

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38352/psn-pdf
    June 14, 2011 - Developing a tool for assessing competency in root cause analysis. … Developing a tool for assessing competency in root cause analysis. … https://psnet.ahrq.gov/issue/developing-tool-assessing-competency-root-cause-analysis Root cause analysis … /primer/root-cause-analysis https://psnet.ahrq.gov/issue/veterans-affairs-root-cause-analysis-system-action … https://psnet.ahrq.gov/issue/effectiveness-and-efficiency-root-cause-analysis-medicine

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44098/psn-pdf
    April 29, 2015 - Evaluation of the suitability of root cause analysis frameworks for the investigation of community-acquired … pressure ulcers: a systematic review and documentary analysis. … Evaluation of the suitability of root cause analysis frameworks for the investigation of community-acquired … pressure ulcers: a systematic review and documentary analysis. … - acquired This systematic review discusses how root cause analysis methods can be used to understand

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45225/psn-pdf
    June 15, 2016 - A case of transfusion error in a trauma patient with subsequent root cause analysis leading to institutional … A case of transfusion error in a trauma patient with subsequent root cause analysis leading to institutional … https://psnet.ahrq.gov/issue/case-transfusion-error-trauma-patient-subsequent-root-cause-analysis-leading … This case analysis discusses a wrong-patient transfusion error in a hospital's emergency room and reviews … findings of the subsequent root cause analysis, which determined training weaknesses, time pressures

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34698/psn-pdf
    January 04, 2017 - Using Health Care Failure Mode and Effect Analysis: the VA National Center for Patient Safety's prospective … risk analysis system. … risk analysis system. … - safetys The authors describe their adaptation of failure mode and effects analysis, a prospective … Their system, Health Care Failure Mode Effects Analysis (HFMEA), is documented in detail, including

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42446/psn-pdf
    May 19, 2014 - The Human Factors Analysis Classification System (HFACS) applied to health care. … The Human Factors Analysis Classification System (HFACS) applied to health care. … https://psnet.ahrq.gov/issue/human-factors-analysis-classification-system-hfacs-applied-health-care … This study reports on one health system's experience using the Human Factors Analysis Classification … ://psnet.ahrq.gov/primer/root-cause-analysis https://psnet.ahrq.gov/issue/effectiveness-and-efficiency-root-cause-analysis-medicine

  7. 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

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45710/psn-pdf
    December 22, 2017 - Our current approach to root cause analysis: is it contributing to our failure to improve patient safety … Our current approach to root cause analysis: is it contributing to our failure to improve patient safety … https://psnet.ahrq.gov/issue/our-current-approach-root-cause-analysis-it-contributing-our-failure-improve … - patient-safety Root cause analysis (RCA) is a process frequently employed by health care institutions … https://psnet.ahrq.gov/primer/root-cause-analysis https://psnet.ahrq.gov/issue/problem-root-cause-analysis

  9. 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.

  10. 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

  11. 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.

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45298/psn-pdf
    April 22, 2017 - The problem with root cause analysis. April 22, 2017 Peerally MF, Carr S, Waring J, et al. … The problem with root cause analysis. … https://psnet.ahrq.gov/issue/problem-root-cause-analysis Root cause analysis (RCA) is a strategy to … this commentary suggests that challenges such as inappropriate focus on single-point causation, poor analysis … https://psnet.ahrq.gov/issue/problem-root-cause-analysis https://psnet.ahrq.gov/primer/root-cause-analysis

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46152/psn-pdf
    May 31, 2017 - Root cause analysis of adverse events in an outpatient anticoagulation management consortium. … Root Cause Analysis of Adverse Events in an Outpatient Anticoagulation Management Consortium. … https://psnet.ahrq.gov/issue/root-cause-analysis-adverse-events-outpatient-anticoagulation-management … Unlike a prior study, researchers did not include patient perspectives in their analysis, which may … https://psnet.ahrq.gov/issue/root-cause-analysis-ambulatory-adverse-drug-events-present-emergency-department

  14. 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

  15. 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.

  16. 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.

  17. 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

  18. Ch 11-User-Guide-To-Ocer 130129 (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/ch_11-user-guide-to-ocer_130129.pdf
    January 03, 2012 - This chapter considers the forms of sensitivity analysis that can be included in the analysis of an … Also, estimators resulting from the IV analysis may differ from main analysis estimators (see Supplement … Sensitivity Analysis [propensity score] to a relative risk of 1.64 [traditional regression analysis … (http://www.drugepi.org/dope- downloads/#Sensitivity Analysis) Other tools for sensitivity analysis … The use of sensitivity analysis to examine the underlying assumptions in the analysis process will

  19. 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

  20. 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
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