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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37562/psn-pdf
    June 14, 2011 - Effectiveness and efficiency of root cause analysis in medicine. June 14, 2011 Wu AW. … Effectiveness and Efficiency of Root Cause Analysis in Medicine. JAMA. 2008;299(6):685-687. … https://psnet.ahrq.gov/issue/effectiveness-and-efficiency-root-cause-analysis-medicine Application of … root cause analysis (RCA) continues to serve an important role in improving patient safety and quality … /primer/root-cause-analysis https://psnet.ahrq.gov/issue/veterans-affairs-root-cause-analysis-system-action

  2. 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

  3. Medication errors related to product names. | PSNet

    psnet.ahrq.gov/issue/medication-errors-related-product-names
    January 02, 2017 - 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.

  4. Drug related admissions to a cardiology department; frequency and avoidability. | PSNet

    psnet.ahrq.gov/issue/drug-related-admissions-cardiology-department-frequency-and-avoidability
    August 20, 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.

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38762/psn-pdf
    June 28, 2011 - Analysis of unintended events in hospitals: inter-rater reliability of constructing causal trees and … Analysis of unintended events in hospitals: inter-rater reliability of constructing causal trees and … https://psnet.ahrq.gov/issue/analysis-unintended-events-hospitals-inter-rater-reliability-constructing-causal … - trees-and Root cause analysis is commonly used to identify underlying system causes of adverse events … https://psnet.ahrq.gov/primer/root-cause-analysis

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42179/psn-pdf
    April 10, 2013 - Training health care professionals in root cause analysis: a cross-sectional study of post-training … Training health care professionals in root cause analysis: a cross-sectional study of post-training … https://psnet.ahrq.gov/issue/training-health-care-professionals-root-cause-analysis-cross-sectional-study … post-training According to this study, the majority of health care providers trained in root cause analysis … https://psnet.ahrq.gov/primer/root-cause-analysis

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39460/psn-pdf
    March 23, 2011 - Applying root cause analysis to improve patient safety: decreasing falls in postpartum women. … Applying root cause analysis to improve patient safety: decreasing falls in postpartum women. … https://psnet.ahrq.gov/issue/applying-root-cause-analysis-improve-patient-safety-decreasing-falls- postpartum-women … This Taiwanese study used root cause analysis to identify causal factors for falls in postpartum women … https://psnet.ahrq.gov/issue/applying-root-cause-analysis-improve-patient-safety-decreasing-falls-postpartum-women

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41126/psn-pdf
    February 01, 2013 - The AMÉLIE project: failure mode, effects and criticality analysis: a model to evaluate the nurse medication … The AMÉLIE project: failure mode, effects and criticality analysis: a model to evaluate the nurse medication … https://psnet.ahrq.gov/issue/amelie-project-failure-mode-effects-and-criticality-analysis-model-evaluate … - nurse-medication This study reports on a multidisciplinary failure mode and effect analysis of nursing … https://psnet.ahrq.gov/issue/using-health-care-failure-mode-and-effect-analysis-va-national-center-patient-safetys

  9. 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.

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40736/psn-pdf
    January 04, 2012 - Preventing wrong site, procedure, and patient events using a common cause analysis. … Preventing wrong site, procedure, and patient events using a common cause analysis. … https://psnet.ahrq.gov/issue/preventing-wrong-site-procedure-and-patient-events-using-common-cause- analysis … https://psnet.ahrq.gov/issue/preventing-wrong-site-procedure-and-patient-events-using-common-cause-analysis … https://psnet.ahrq.gov/primer/root-cause-analysis

  11. Drug package inserts get mixed reception. | PSNet

    psnet.ahrq.gov/issue/drug-package-inserts-get-mixed-reception
    September 12, 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.

  12. Medication errors and drug-dispensing systems in a hospital pharmacy. | PSNet

    psnet.ahrq.gov/issue/medication-errors-and-drug-dispensing-systems-hospital-pharmacy
    November 18, 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.

  13. ISMP's Guidelines for Standard Order Sets. | PSNet

    psnet.ahrq.gov/issue/ismps-guidelines-standard-order-sets
    May 11, 2017 - July 10, 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.

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46075/psn-pdf
    May 03, 2017 - ED misdiagnosis of cerebrovascular events in the era of modern neuroimaging: a meta-analysis. … ED misdiagnosis of cerebrovascular events in the era of modern neuroimaging: A meta-analysis. … https://psnet.ahrq.gov/issue/ed-misdiagnosis-cerebrovascular-events-era-modern-neuroimaging-meta- analysis … This meta-analysis of diagnostic accuracy for cerebrovascular events in the emergency department found … https://psnet.ahrq.gov/issue/ed-misdiagnosis-cerebrovascular-events-era-modern-neuroimaging-meta-analysis

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35975/psn-pdf
    June 14, 2011 - A root cause analysis of clinical error: confronting the disjunction between formal rules and situated … A root cause analysis of clinical error: confronting the disjunction between formal rules and situated … https://psnet.ahrq.gov/issue/root-cause-analysis-clinical-error-confronting-disjunction-between-formal-rules … - and-situated The authors present the results of a root cause analysis (RCA) of an accidental morphine … https://psnet.ahrq.gov/primer/root-cause-analysis

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43006/psn-pdf
    April 02, 2014 - Hamilton Acute Pain Service Safety Study: using root cause analysis to reduce the incidence of adverse … Hamilton acute pain service safety study: using root cause analysis to reduce the incidence of adverse … https://psnet.ahrq.gov/issue/hamilton-acute-pain-service-safety-study-using-root-cause-analysis-reduce … - incidence-adverse The implementation of formal root cause analysis was associated with substantial … https://psnet.ahrq.gov/primer/root-cause-analysis

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38779/psn-pdf
    July 15, 2009 - Prospective risk analysis of health care processes: a systematic evaluation of the use of HFMEA in Dutch … Prospective risk analysis of health care processes: a systematic evaluation of the use of HFMEA in Dutch … https://psnet.ahrq.gov/issue/prospective-risk-analysis-health-care-processes-systematic-evaluation-use … - hfmea-dutch-health This study analyzed 13 failure mode and effect analysis (FMEA) efforts to understand … https://psnet.ahrq.gov/issue/prospective-risk-analysis-health-care-processes-systematic-evaluation-use-hfmea-dutch-health

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36689/psn-pdf
    June 14, 2011 - Root cause analysis. June 14, 2011 Stecker MS. Root cause analysis. … https://psnet.ahrq.gov/issue/root-cause-analysis The author provides an introduction to root cause analysis … https://psnet.ahrq.gov/issue/root-cause-analysis https://psnet.ahrq.gov/primer/root-cause-analysis

  19. 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

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35703/psn-pdf
    July 13, 2010 - Injury and liability associated with monitored anesthesia care: a closed claims analysis. … Injury and liability associated with monitored anesthesia care: a closed claims analysis. … https://psnet.ahrq.gov/issue/injury-and-liability-associated-monitored-anesthesia-care-closed-claims- analysis … Investigators performed a detailed analysis of more than 120 MAC claims, compared them with those of … https://psnet.ahrq.gov/issue/adverse-respiratory-events-anesthesia-closed-claims-analysis
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