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  1. 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

  2. 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

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37086/psn-pdf
    October 03, 2011 - Failure mode and effects analysis: a useful tool for risk identification and injury prevention. … Failure mode and effects analysis: a useful tool for risk identification and injury prevention. … https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-useful-tool-risk-identification-and-injury … proactive risk assessment and provides insights on the successful use of failure mode and effects analysis … https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-useful-tool-risk-identification-and-injury-prevention

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38753/psn-pdf
    July 01, 2009 - Evaluation of safety in a radiation oncology setting using failure mode and effects analysis. … Evaluation of safety in a radiation oncology setting using failure mode and effects analysis. … /psnet.ahrq.gov/issue/evaluation-safety-radiation-oncology-setting-using-failure-mode-and-effects- analysis … Failure mode and effects analysis was used to prospectively analyze an external beam radiation therapy … ://psnet.ahrq.gov/issue/evaluation-safety-radiation-oncology-setting-using-failure-mode-and-effects-analysis

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41554/psn-pdf
    January 03, 2017 - Using root cause analysis to reduce falls with injury in community settings. … Using root cause analysis to reduce falls with injury in community settings. … https://psnet.ahrq.gov/issue/using-root-cause-analysis-reduce-falls-injury-community-settings This study … used root cause analysis (RCA) to identify hazards leading to falls among community-dwelling elderly … /psnet.ahrq.gov/primer/root-cause-analysis https://psnet.ahrq.gov/primer/ambulatory-care-safety

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36331/psn-pdf
    October 26, 2010 - Using system analysis to build a safety culture: improving the reliability of epidural analgesia. … Using system analysis to build a safety culture: improving the reliability of epidural analgesia. … https://psnet.ahrq.gov/issue/using-system-analysis-build-safety-culture-improving-reliability-epidural … - analgesia The authors describe the systematic analysis of an incident involving inappropriate use … https://psnet.ahrq.gov/issue/using-system-analysis-build-safety-culture-improving-reliability-epidural-analgesia

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40218/psn-pdf
    December 29, 2014 - Preventable adverse drug events and their causes and contributing factors: the analysis of register … Preventable adverse drug events and their causes and contributing factors: the analysis of register … ://psnet.ahrq.gov/issue/preventable-adverse-drug-events-and-their-causes-and-contributing-factors- analysis-register … https://psnet.ahrq.gov/issue/preventable-adverse-drug-events-and-their-causes-and-contributing-factors-analysis-register … https://psnet.ahrq.gov/issue/preventable-adverse-drug-events-and-their-causes-and-contributing-factors-analysis-register

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37132/psn-pdf
    June 14, 2011 - Preventing medication errors in community pharmacy: root-cause analysis of transcription errors. … Preventing medication errors in community pharmacy: root- cause analysis of transcription errors. … https://psnet.ahrq.gov/issue/preventing-medication-errors-community-pharmacy-root-cause-analysis- transcription-errors … https://psnet.ahrq.gov/issue/preventing-medication-errors-community-pharmacy-root-cause-analysis-transcription-errors … https://psnet.ahrq.gov/primer/root-cause-analysis https://psnet.ahrq.gov//#adversedrugevent

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44339/psn-pdf
    July 29, 2015 - Rapid response systems: a systematic review and meta- analysis. … Rapid response systems: a systematic review and meta-analysis. … https://psnet.ahrq.gov/issue/rapid-response-systems-systematic-review-and-meta-analysis This meta-analysis … This analysis supports the current widespread implementation of rapid response. … https://psnet.ahrq.gov/issue/rapid-response-systems-systematic-review-and-meta-analysis https://psnet.ahrq.gov

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42670/psn-pdf
    January 09, 2014 - Meta-analysis of surgical safety checklist effects on teamwork, communication, morbidity, mortality, … Meta-analysis of surgical safety checklist effects on teamwork, communication, morbidity, mortality, … https://psnet.ahrq.gov/issue/meta-analysis-surgical-safety-checklist-effects-teamwork-communication- … morbidity-mortality This meta-analysis of 19 surgical checklist studies found that checklists improved … https://psnet.ahrq.gov/issue/meta-analysis-surgical-safety-checklist-effects-teamwork-communication-morbidity-mortality

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34794/psn-pdf
    November 18, 2015 - Accident analysis of large-scale technological disasters applied to an anaesthetic complication. … Accident analysis of large-scale technological disasters applied to an anaesthetic complication. … https://psnet.ahrq.gov/issue/accident-analysis-large-scale-technological-disasters-applied-anaesthetic … The model discussed focuses on two types of failures, which share equal importance in analysis but distinguish … They conclude that analysis of past disasters has offered a useful model to differentiate provider from

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39948/psn-pdf
    December 21, 2014 - Wrong-site and wrong-patient procedures in the Universal Protocol era: analysis of a prospective database … Wrong-site and wrong-patient procedures in the universal protocol era: analysis of a prospective database … https://psnet.ahrq.gov/issue/wrong-site-and-wrong-patient-procedures-universal-protocol-era-analysis- … However, this analysis of WSPEs that were voluntarily reported to a Colorado malpractice insurance company … Root cause analysis revealed a number of contributing causes, with diagnostic errors and communication

  13. National Patient Safety Goals. | PSNet

    psnet.ahrq.gov/issue/national-patient-safety-goals
    May 30, 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.

  14. ISMP Targeted Medication Safety Best Practices for Community Pharmacy. | PSNet

    psnet.ahrq.gov/issue/ismp-targeted-medication-safety-best-practices-community-pharmacy
    March 21, 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.

  15. 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.

  16. 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.

  17. 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.

  18. 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.

  19. 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.

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35434/psn-pdf
    June 14, 2011 - Turning the medical gaze in upon itself: root cause analysis and the investigation of clinical error … Turning the medical gaze in upon itself: root cause analysis and the investigation of clinical error … https://psnet.ahrq.gov/issue/turning-medical-gaze-upon-itself-root-cause-analysis-and-investigation-clinical … - error This study discusses the translocation of root cause analysis (RCA) techniques from non-health … playing-well-others-translocational-research-patient-safety https://psnet.ahrq.gov/primer/root-cause-analysis
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