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  1. Implementing a bar-code medication administration system. | PSNet

    psnet.ahrq.gov/issue/implementing-bar-code-medication-administration-system
    May 11, 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.

  2. Preventing harm from high-alert medications. | PSNet

    psnet.ahrq.gov/issue/preventing-harm-high-alert-medications
    August 14, 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.

  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/39735/psn-pdf
    January 03, 2017 - A practical guide to Failure Mode and Effects Analysis in health care: making the most of the team and … A practical guide to Failure Mode and Effects Analysis in health care: making the most of the team and … https://psnet.ahrq.gov/issue/practical-guide-failure-mode-and-effects-analysis-health-care-making-most … team-and-its This commentary describes one hospital's experience implementing Failure Mode and Effects Analysis … https://psnet.ahrq.gov/issue/practical-guide-failure-mode-and-effects-analysis-health-care-making-most-team-and-its

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42329/psn-pdf
    December 18, 2014 - Health care failure mode and effect analysis to reduce NICU line–associated bloodstream infections. … Health care failure mode and effect analysis to reduce NICU line-associated bloodstream infections. … https://psnet.ahrq.gov/issue/health-care-failure-mode-and-effect-analysis-reduce-nicu-line-associated … - bloodstream Successful application of a failure mode and effect analysis approach resulted in a marked … https://psnet.ahrq.gov/issue/health-care-failure-mode-and-effect-analysis-reduce-nicu-line-associated-bloodstream

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44967/psn-pdf
    March 16, 2016 - Wrong site surgery: a critical incident analysis of a near miss. March 16, 2016 Tichanow S. … Wrong site surgery: A critical incident analysis of a near miss. … https://psnet.ahrq.gov/issue/wrong-site-surgery-critical-incident-analysis-near-miss Despite efforts … https://psnet.ahrq.gov/issue/wrong-site-surgery-critical-incident-analysis-near-miss https://psnet.ahrq.gov … https://psnet.ahrq.gov/issue/using-near-misses-analysis-prevent-wrong-site-surgery https://psnet.ahrq.gov

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38727/psn-pdf
    November 25, 2009 - FMEA team performance in health care: a qualitative analysis of team member perceptions. … https://psnet.ahrq.gov/issue/fmea-team-performance-health-care-qualitative-analysis-team-member- perceptions … Failure mode and effect analysis (FMEA), a tool that allows prospective risk assessment, has been applied … https://psnet.ahrq.gov/issue/fmea-team-performance-health-care-qualitative-analysis-team-member-perceptions … https://psnet.ahrq.gov/issue/fmea-team-performance-health-care-qualitative-analysis-team-member-perceptions

  8. Labeling morphine milligram equivalents on opioid packaging: a potential patient safety intervention. | PSNet

    psnet.ahrq.gov/issue/labeling-morphine-milligram-equivalents-opioid-packaging-potential-patient-safety
    March 06, 2019 - 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. Predictors of warfarin-associated adverse events in hospitalized patients: opportunities to prevent patient harm. | PSNet

    psnet.ahrq.gov/issue/predictors-warfarin-associated-adverse-events-hospitalized-patients-opportunities-prevent
    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.

  10. Impact of a standard medication chart on prescribing errors: a before-and-after audit. | PSNet

    psnet.ahrq.gov/issue/impact-standard-medication-chart-prescribing-errors-and-after-audit
    May 02, 2012 - 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. 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

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41858/psn-pdf
    November 21, 2012 - Disorganized care: the findings of an iterative, in-depth analysis of surgical morbidity and mortality … Disorganized care: the findings of an iterative, in-depth analysis of surgical morbidity and mortality … https://psnet.ahrq.gov/issue/disorganized-care-findings-iterative-depth-analysis-surgical-morbidity-and … conferences over a 3-year period at one academic hospital and used insights from a modified root cause analysis … https://psnet.ahrq.gov/primer/systems-approach https://psnet.ahrq.gov/primer/root-cause-analysis https

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38343/psn-pdf
    December 09, 2014 - Liability associated with obstetric anesthesia: a closed claims analysis. … Liability associated with obstetric anesthesia: a closed claims analysis. … https://psnet.ahrq.gov/issue/liability-associated-obstetric-anesthesia-closed-claims-analysis The use … https://psnet.ahrq.gov/issue/liability-associated-obstetric-anesthesia-closed-claims-analysis https:/ … https://psnet.ahrq.gov/issue/adverse-respiratory-events-anesthesia-closed-claims-analysis

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38207/psn-pdf
    January 15, 2009 - Analysis of medical emergency team calls comparing subjective to "objective" call criteria. … Analysis of medical emergency team calls comparing subjective to "objective" call criteria. … https://psnet.ahrq.gov/issue/analysis-medical-emergency-team-calls-comparing-subjective-objective-call … This analysis conducted at six Australian hospitals found that nurses' general concern about a patient … https://psnet.ahrq.gov/issue/analysis-medical-emergency-team-calls-comparing-subjective-objective-call-criteria

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43501/psn-pdf
    September 10, 2014 - Emergency department patient safety incident characterization: an observational analysis of the findings … Emergency department patient safety incident characterization: an observational analysis of the findings … /psnet.ahrq.gov/issue/emergency-department-patient-safety-incident-characterization-observational- analysis-findings … Analysis of the data revealed that most emergency department patient safety incidents were primarily … ://psnet.ahrq.gov/issue/emergency-department-patient-safety-incident-characterization-observational-analysis-findings

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38735/psn-pdf
    June 24, 2009 - Reflection and analysis of how pharmacy students learn to communicate about medication errors. … Reflection and analysis of how pharmacy students learn to communicate about medication errors. … https://psnet.ahrq.gov/issue/reflection-and-analysis-how-pharmacy-students-learn-communicate-about- … https://psnet.ahrq.gov/issue/reflection-and-analysis-how-pharmacy-students-learn-communicate-about-medication-errors … https://psnet.ahrq.gov/issue/effectiveness-and-efficiency-root-cause-analysis-medicine https://psnet.ahrq.gov

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43565/psn-pdf
    March 22, 2016 - The role of failure mode and effects analysis in health care. March 22, 2016 Fibuch E, Ahmed A. … The role of failure mode and effects analysis in health care. Physician Exec. 2014;40(4):28-32. … https://psnet.ahrq.gov/issue/role-failure-mode-and-effects-analysis-health-care Failure mode and effects … analysis (FMEA) has been recommended as a method to detect safety hazards and proactively address system … https://psnet.ahrq.gov/issue/role-failure-mode-and-effects-analysis-health-care https://psnet.ahrq.gov

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43777/psn-pdf
    January 01, 2015 - Smartphones let surgeons know WhatsApp: an analysis of communication in emergency surgical teams. … Smartphones let surgeons know WhatsApp: an analysis of communication in emergency surgical teams. … https://psnet.ahrq.gov/issue/smartphones-let-surgeons-know-whatsapp-analysis-communication- emergency-surgical-teams … Analysis of messages found it to be a safe and efficient method of communication that was perceived … https://psnet.ahrq.gov/issue/smartphones-let-surgeons-know-whatsapp-analysis-communication-emergency-surgical-teams

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42469/psn-pdf
    August 07, 2013 - Characteristics of paid malpractice claims settled in and out of court in the USA: a retrospective analysis … Characteristics of paid malpractice claims settled in and out of court in the USA: a retrospective analysis … psnet.ahrq.gov/issue/characteristics-paid-malpractice-claims-settled-and-out-court-usa- retrospective-analysis … This analysis of paid malpractice claims from the National Practitioner Data Bank found that the vast … psnet.ahrq.gov/issue/characteristics-paid-malpractice-claims-settled-and-out-court-usa-retrospective-analysis

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43997/psn-pdf
    August 02, 2015 - Sentinel events, serious reportable events, and root cause analysis. … Sentinel events, serious reportable events, and root cause analysis. … https://psnet.ahrq.gov/issue/sentinel-events-serious-reportable-events-and-root-cause-analysis This … authors use ophthalmologic examples to illustrate the elements of a systematic approach to root cause analysis … https://psnet.ahrq.gov/issue/sentinel-events-serious-reportable-events-and-root-cause-analysis https:
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