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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42236/psn-pdf
    May 01, 2013 - Nursing student medication errors: a case study using root cause analysis. … Nursing student medication errors: a case study using root cause analysis. … https://psnet.ahrq.gov/issue/nursing-student-medication-errors-case-study-using-root-cause-analysis … This commentary examines a medication error involving insulin using root case analysis to identify factors … https://psnet.ahrq.gov/issue/nursing-student-medication-errors-case-study-using-root-cause-analysis https

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37095/psn-pdf
    September 04, 2010 - Prospective error recording in surgery: an analysis of 1108 elective neurosurgical cases. … Prospective error recording in surgery: an analysis of 1108 elective neurosurgical cases. … https://psnet.ahrq.gov/issue/prospective-error-recording-surgery-analysis-1108-elective-neurosurgical … - cases This analysis of cases performed by a single neurosurgeon found that errors occurred frequently … https://psnet.ahrq.gov/issue/prospective-error-recording-surgery-analysis-1108-elective-neurosurgical-cases

  3. 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.

  4. 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.

  5. 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.

  6. 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.

  7. 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.

  8. 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.

  9. 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.

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36800/psn-pdf
    August 26, 2011 - Application of the human factors analysis and classification system methodology to the cardiovascular … Application of the human factors analysis and classification system methodology to the cardiovascular … https://psnet.ahrq.gov/issue/application-human-factors-analysis-and-classification-system-methodology … - cardiovascular The authors adapted an incident analysis model used in aviation to understand the … https://psnet.ahrq.gov/issue/application-human-factors-analysis-and-classification-system-methodology-cardiovascular

  11. 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

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44909/psn-pdf
    March 23, 2016 - Root Cause Analysis Workbook for Community/Ambulatory Pharmacy. … https://psnet.ahrq.gov/issue/root-cause-analysis-workbook-communityambulatory-pharmacy Root cause analysis … This workbook illustrates how root cause analysis can be applied to community pharmacy services to identify … https://psnet.ahrq.gov/issue/root-cause-analysis-workbook-communityambulatory-pharmacy https://psnet.ahrq.gov … /primer/root-cause-analysis https://psnet.ahrq.gov/issue/dispensing-errors-community-pharmacy-perceived-influence-sociotechnical-factors

  13. 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

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40004/psn-pdf
    February 01, 2011 - Application of failure mode and effect analysis in a radiology department. … Application of Failure Mode and Effect Analysis in a Radiology Department. … https://psnet.ahrq.gov/issue/application-failure-mode-and-effect-analysis-radiology-department This … commentary introduces the failure mode and effects analysis process developed by the United States Department … https://psnet.ahrq.gov/issue/application-failure-mode-and-effect-analysis-radiology-department https:

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39865/psn-pdf
    May 28, 2014 - Failure Mode and Effects Analysis in Health Care: Proactive Risk Reduction, Third Edition. … https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-health-care-proactive-risk-reduction-third … edition This publication provides strategies for organizations to utilize the Failure Mode and Effects Analysis … https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-health-care-proactive-risk-reduction-third-edition … https://psnet.ahrq.gov/issue/failure-mode-and-effects-analysis-health-care-proactive-risk-reduction-third-edition

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43795/psn-pdf
    December 17, 2014 - Systematic Systems Analysis: A Practical Approach to Patient Safety Reviews. … https://psnet.ahrq.gov/issue/systematic-systems-analysis-practical-approach-patient-safety-reviews Drawing … from human factors and system analysis techniques, this guide describes an approach to identifying … https://psnet.ahrq.gov/issue/systematic-systems-analysis-practical-approach-patient-safety-reviews https … https://psnet.ahrq.gov/issue/cross-sectional-analysis-investigating-organizational-factors-influence-near-miss-error

  17. 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

  18. 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

  19. Slide 1

    effectivehealthcare.ahrq.gov/sites/default/files/sensitivity-analysis-chapter-11.pptx
    January 01, 2013 - Sensitivity analysis. In: Velentgas P and Dreyer NA, eds. … Sensitivity analysis. In: Velentgas P and Dreyer NA, eds. … Sensitivity analysis. In: Velentgas P and Dreyer NA, eds. … sources as a sensitivity analysis. … Instrumental variable analysis This type of analysis is based on different assumptions than conventional

  20. 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
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