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  1. 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

  2. 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

  3. 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

  4. 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

  5. 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.

  6. 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

  7. The health information infrastructure in America today . . . . (pdf file)

    hcup-us.ahrq.gov/datainnovations/clinicaldata/AHRQHCUPfinalNov09BDiefenbach.pdf
    November 01, 2009 - Agency for Health Care Administration Florida Center for Health Information and Policy Analysis HCUP … Learned Agency for Health Care Administration Florida Center for Health Information and Policy Analysis … Hospital 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 Data … Agency for Health Care Administration Florida Center for Health Information and Policy Analysis LOINC

  8. S89 (pdf file)

    effectivehealthcare.ahrq.gov/sites/default/files/s89.pdf
    October 01, 2007 - Two forms of maxSPRT were implemented: an analysis using concurrent matched controls, and an analysis … Analysis Using Matched Controls We used 2 forms of maxSPRT in this study. … Meningococcal Vaccinations in the Analysis for This Outcome* Cumulative No. … The x-axis shows how the LLR changes each week during the analysis. … However, analysis using matched controls has important limitations.

  9. 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

  10. 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

  11. 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

  12. 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

  13. Wrong drug and wrong dose dispensing errors identified in pharmacist professional liability claims. | PSNet

    psnet.ahrq.gov/issue/wrong-drug-and-wrong-dose-dispensing-errors-identified-pharmacist-professional-liability
    August 31, 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.

  14. 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

  15. 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

  16. 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

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38861/psn-pdf
    August 26, 2009 - Survey evaluation of the National Patient Safety Agency’s Root Cause Analysis training programme in … Survey evaluation of the National Patient Safety Agency's Root Cause Analysis training programme in … https://psnet.ahrq.gov/issue/survey-evaluation-national-patient-safety-agencys-root-cause-analysis- … training-programme Formal root cause analysis (RCA) training conducted by the United Kingdom's National … https://psnet.ahrq.gov/primer/root-cause-analysis https://psnet.ahrq.gov/issue/national-patient-safety-agency-npsa

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38697/psn-pdf
    June 10, 2009 - A report card system using error profile analysis and concurrent morbidity and mortality review: surgical … outcome analysis, part II. … A report card system using error profile analysis and concurrent morbidity and mortality review: surgical … outcome analysis, part II. … https://psnet.ahrq.gov/issue/report-card-system-using-error-profile-analysis-and-concurrent-morbidity-and

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45827/psn-pdf
    January 24, 2018 - Using failure mode and effects analysis to reduce patient safety risks related to the dispensing process … Using Failure mode and Effects Analysis to reduce patient safety risks related to the dispensing process … https://psnet.ahrq.gov/issue/using-failure-mode-and-effects-analysis-reduce-patient-safety-risks-related … - dispensing Failure mode and effect analysis is a tool commonly used to proactively assess the reliability … The authors describe the application of failure mode and effect analysis to identify failure modes in

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34803/psn-pdf
    January 05, 2017 - Systematic root cause analysis of adverse drug events in a tertiary referral hospital. … Systematic Root Cause Analysis of Adverse Drug Events in a Tertiary Referral Hospital. … This study examines the utility of root cause analysis (RCA) to identify, investigate, and address … The authors conclude that systematic application of root cause analysis, coupled with implementation … https://psnet.ahrq.gov/primer/root-cause-analysis https://psnet.ahrq.gov//#adversedrugevent
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