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psnet.ahrq.gov/issue/incorrect-surgical-procedures-within-and-outside-operating-room
November 21, 2011 - This study used Veterans Administration data to analyze the broader concept of "incorrect" surgical procedures
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psnet.ahrq.gov/issue/analysis-electronic-health-record-related-patient-safety-concerns
January 21, 2019 - framework that takes into account both technical aspects and human factors engineering principles to analyze
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psnet.ahrq.gov/issue/demonstrating-high-reliability-accountability-measures-johns-hopkins-hospital
January 27, 2016 - They also employed the Lean framework of define-measure-analyze-improve-control to help teams systematically
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psnet.ahrq.gov/issue/fda-drug-prescribing-warnings-black-box-half-empty-or-half-full
December 19, 2011 - Using a retrospective method to analyze nearly 1 million automated claims data, investigators determined
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psnet.ahrq.gov/issue/supplemental-nurse-staffing-hospitals-and-quality-care
February 09, 2011 - In this study, researchers sought to characterize the qualifications of temporary nurses and analyze
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psnet.ahrq.gov/issue/impact-inpatient-harms-hospital-finances-and-patient-clinical-outcomes
February 28, 2018 - financial models, including a novel approach that accounts for various diagnosis-related groups, to analyze
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psnet.ahrq.gov/issue/turning-medical-gaze-upon-itself-root-cause-analysis-and-investigation-clinical-error
June 14, 2011 - This discussion is illustrated with actual excerpts from an RCA, after which the authors analyze the
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psnet.ahrq.gov/issue/beating-weekend-trend-increased-mortality-older-adult-traumatic-brain-injury-tbi-patients
December 21, 2014 - A limitation of this study is that the authors were not able to analyze outcomes for patients cared for
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psnet.ahrq.gov/issue/recognizing-our-biases-understanding-evidence-and-responding-equitably-application
April 05, 2023 - qualitative study of a hospital-wide clinical event debriefing program and a novel qualitative model to analyze
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psnet.ahrq.gov/issue/honesty-and-transparency-indispensable-clinical-mission-parts-i-iii
November 11, 2020 - qualitative study of a hospital-wide clinical event debriefing program and a novel qualitative model to analyze
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psnet.ahrq.gov/issue/qi-initiative-implementing-patient-handoff-checklist-pediatric-hospitalist-attendings
July 28, 2021 - qualitative study of a hospital-wide clinical event debriefing program and a novel qualitative model to analyze
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psnet.ahrq.gov/issue/debrief-it-all-tool-inclusion-safety-ii
June 08, 2022 - qualitative study of a hospital-wide clinical event debriefing program and a novel qualitative model to analyze
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psnet.ahrq.gov/issue/root-causes-adverse-drug-events-hospitals-and-artificial-intelligence-capabilities-prevention
May 20, 2020 - View More
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Using the Generic Analysis Method to analyze
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psnet.ahrq.gov/issue/delays-diagnosis-treatment-and-surgery-root-causes-actions-taken-and-recommendations
March 25, 2020 - July 19, 2023
Using the Generic Analysis Method to analyze sentinel event reports across
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psnet.ahrq.gov/issue/death-suicide-within-1-week-hospital-discharge-retrospective-study-root-cause-analysis
May 04, 2022 - May 24, 2023
Using the Generic Analysis Method to analyze sentinel event reports across
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psnet.ahrq.gov/issue/redesigning-rounds-towards-more-purposeful-approach-inpatient-teaching-and-learning
February 02, 2022 - Missed Diagnosis
March 1, 2017
Use of a novel, modified fishbone diagram to analyze
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psnet.ahrq.gov/issue/next-organizational-challenge-finding-and-addressing-diagnostic-error
November 16, 2022 - September 23, 2020
Use of a novel, modified fishbone diagram to analyze diagnostic errors
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psnet.ahrq.gov/issue/covid-19-pandemic-preparation-using-simulation-systems-based-learning-prepare-largest
August 19, 2020 - qualitative study of a hospital-wide clinical event debriefing program and a novel qualitative model to analyze
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psnet.ahrq.gov/issue/healthcare-professionals-views-feedback-patient-safety-culture-assessment
October 25, 2023 - May 18, 2022
Using the Generic Analysis Method to analyze sentinel event reports across
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psnet.ahrq.gov/issue/retrospective-review-emergency-response-activations-during-13-year-period-tertiary-care
August 26, 2020 - qualitative study of a hospital-wide clinical event debriefing program and a novel qualitative model to analyze