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psnet.ahrq.gov/node/42043/psn-pdf
February 13, 2013 - reasons-accident-causation-model-application-adverse-events-acute-care
This commentary discusses how Reason's accident causation model is used to analyze
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psnet.ahrq.gov/node/36993/psn-pdf
September 15, 2011 - transdisciplinary-team-acting-evidence-through-analyses-moot-malpractice-
cases
The author proposes that nurse-led transdisciplinary teams analyze
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psnet.ahrq.gov/node/859299/psn-pdf
December 20, 2023 - Operating room black boxes are a way to capture video, audio, and other data in real time to prevent and
analyze
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psnet.ahrq.gov/issue/survey-results-reveal-tubing-misconnections-are-common-and-underreported-parts-i-and-ii
December 18, 2024 - Strategies include training patients and clinicians, using simulation to analyze processes for potential
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psnet.ahrq.gov/node/41931/psn-pdf
December 19, 2012 - issue/preventing-wrong-site-surgery-minnesota-5-year-journey
Discussing a 5-year effort to report, analyze
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psnet.ahrq.gov/node/39180/psn-pdf
December 16, 2009 - description-inpatient-medication-management-using-cognitive-work-analysis
This study used cognitive engineering techniques to analyze
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psnet.ahrq.gov/node/40044/psn-pdf
December 01, 2010 - nature-causes-and-consequences-unintended-events-surgical-units
Voluntary error reporting combined with root cause analysis was used to analyze
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psnet.ahrq.gov/node/36180/psn-pdf
September 29, 2010 - /why-nurses-make-medication-errors-simulation-study
The investigators used a simulated scenario to analyze
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psnet.ahrq.gov/node/35096/psn-pdf
June 22, 2009 - https://psnet.ahrq.gov/issue/paediatric-adverse-drug-reactions-reported-sweden-1987-2001
The authors analyze
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psnet.ahrq.gov/node/60199/psn-pdf
April 08, 2020 - using-safety-ii-and-resilient-healthcare-principles-learn-never-events
Using a Safety-II framework, the authors used a mixed-methods approach to retrospectively analyze
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psnet.ahrq.gov/node/836915/psn-pdf
April 13, 2022 - teams (e.g. leadership, providers, EHR developers) can now
use the refined SEWA framework to identify, analyze
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psnet.ahrq.gov/node/47952/psn-pdf
January 01, 2020 - cvc-placement-speak-now-or-do-not-use-line
https://psnet.ahrq.gov/issue/use-novel-modified-fishbone-diagram-analyze-diagnostic-errors
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psnet.ahrq.gov/node/60022/psn-pdf
March 11, 2020 - This study used the Systems Engineer Initiative for Patient Safety approach to analyze care transitions
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psnet.ahrq.gov/node/50852/psn-pdf
January 29, 2020 - This study used a failure mode and effects analysis (FMEA) to prospectively analyze
various steps in
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psnet.ahrq.gov/node/72856/psn-pdf
March 17, 2021 - radiation oncology incident learning system with a simplified
failure mode and effects analysis (FMEA) to analyze
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psnet.ahrq.gov/node/838074/psn-pdf
January 01, 2023 - This study used automated language analysis to analyze more than 140,000 reports submitted
by patients
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psnet.ahrq.gov/node/74035/psn-pdf
January 01, 2022 - measuring the severity of patient complaints – the Healthcare Complaints Analysis Tool
– can effectively analyze
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psnet.ahrq.gov/node/867845/psn-pdf
February 26, 2025 - Center for Patient Safety (NCPS) created the Combined Proactive Risk
Assessment (CPRA) technique to analyze … psnet.ahrq.gov//#2
https://psnet.ahrq.gov//#2
objective of CPRA is to utilize institutional databases to analyze … traditional proactive risk assessment techniques to capitalize on data from the VHA
data repositories and analyze
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psnet.ahrq.gov/node/39785/psn-pdf
October 13, 2010 - teams-through
This study used both ethnographic approaches and a structured observation technique to analyze
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psnet.ahrq.gov/training-catalog/learning-errors-analysis-medication-error
Event Description: This recorded one-hour session from NTI 2023 uses a case study approach to analyze