-
psnet.ahrq.gov/node/33570/psn-pdf
June 15, 2024 - potential-improved-teamwork-reduce-medical-errors-emergency-department
https://psnet.ahrq.gov/issue/analysis-surgical-errors-closed-malpractice-claims … The principal goal is to engage clinicians in "meta-cognition" (reflecting on their own thinking),
with
-
psnet.ahrq.gov/node/33600/psn-pdf
June 16, 2024 - Lucian Leape highlighted the issue and presented a framework for
error analysis and prevention that … https://psnet.ahrq.gov/issue/rate-preventable-mortality-hospitalized-patients-systematic-review-and-meta-analysis … Current Context
https://psnet.ahrq.gov/issue/making-health-care-safer-critical-analysis-patient-safety-practices
-
psnet.ahrq.gov/web-mm/diuretics-and-electrolyte-abnormalities
February 15, 2017 - Thiazide-induced hyponatremia: reproducibility by single dose rechallenge and an analysis of pathogenesis … A systematic review and meta-analysis. … primary care patients particularly vulnerable to adverse drug events: cross sectional population database analysis
-
psnet.ahrq.gov/web-mm/right-place-right-drug-wrong-strength
March 26, 2015 - Root cause analysis (RCA) by the safety committee determined the higher concentration of oxycodone solution … Making Health Care Safer: A Critical Analysis of Patient Safety Practices. … Clinical impact of medication review and deprescribing in older inpatients: a systematic review and meta-analysis … 2020
View More
Related Resources
ISMP medication error report analysis
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.176_slideshow.ppt
May 01, 2008 - to AIDS and death before widespread use of highly-active antiretroviral therapy: a collaborative re-analysis … Prognosis of HIV-1-infected patients starting highly active antiretroviral therapy: a collaborative analysis … Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected with HIV in … Expanded screening for HIV in the United States--an analysis of cost-effectiveness.
-
psnet.ahrq.gov/web-mm/do-not-miss-sepsis-needles-viral-haystacks
March 27, 2024 - In addition to the deliberate analysis of a complex scenario using clinical decision support tools, NDM … Global, regional, and national sepsis incidence and mortality, 1990-2017: analysis for the Global Burden … Criteria for pediatric sepsis-a systematic review and meta-analysis by the Pediatric Sepsis Definition … Sepsis alert systems, mortality, and adherence in emergency departments: a systematic review and meta-analysis … Risk assessment of the acute stroke diagnostic process using failure modes, effects, and criticality analysis
-
psnet.ahrq.gov/perspective/becoming-certified-professional-patient-safety-pharmacists-perspective
June 01, 2016 - The exam covers culture, leadership, risk identification and analysis, data management, system design … , mitigating risk, human factors analysis, and external influences on patient safety, error science, … CPPS professionals are more familiar with root cause analysis, failure mode and effect analysis, and … on medication errors, length of stay, and mortality in intensive care units: a systematic review and meta-analysis … in patient safety from patients and healthcare professionals' perspectives: a systematic review and meta-synthesis
-
psnet.ahrq.gov/web-mm/too-many-cooks-kitchen
March 07, 2018 - An Analysis of Trauma Mortality Patterns, 1997-2008. J Trauma 69(3):620-6, 2010. … The association of frailty with adverse outcomes after multisystem trauma: a systematic review and meta-analysis … Aortic stenosis and non-cardiac surgery: A systematic review and meta-analysis.
-
psnet.ahrq.gov/web-mm/do-you-want-everything-done-clarifying-code-status
March 27, 2024 - Survival in cancer patients undergoing in-hospital cardiopulmonary resuscitation: a meta-analysis. … Private patient rooms and hospital-acquired methicillin-resistant Staphylococcus aureus: hospital-level analysis … August 5, 2020
Handoffs and transitions of care: a systematic review, meta-analysis,
-
psnet.ahrq.gov/node/60168/psn-pdf
March 25, 2020 - Root cause analysis is helpful for identifying areas for corrective actions in complex systems. … laboratory testing identification errors: a Laboratory
Medicine Best Practices systematic review and meta-analysis
-
psnet.ahrq.gov/node/49803/psn-pdf
January 01, 2018 - In a recent extensive
analysis of more than 600 outpatient pediatric vaccination error reports, look-alike … Brief clinical report: a systematic review and meta-analysis
of pain memory-reframing interventions
-
psnet.ahrq.gov/innovation/critical-radiology-alert-process
November 16, 2022 - found to have an incidental radiology finding between May 3, 2020, and June 30, 2021, was included in analysis … radiology findings on computed tomography studies in emergency department patients: a systematic review and meta-analysis
-
psnet.ahrq.gov/sites/default/files/2025-03/PSNet%20Webinar%20Feb%202025_0.pdf
January 01, 2025 - Systematic review &
meta-analysis
Hospital mortality Reduced mortality
{RR=0.85; 95% CI, 0.76- … Systematic review
with meta-analysis
Incidence of
cardiorespiratory arrest
Significant reduction … Primary Treatment
protocols,
enhanced data
collection/
analysis
Hospital
mortality, O/E
mortality … Primary RRS Treatment
protocols, enhanced
data collection and
analysis
Incidence of
cardiorespiratory
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.14_slideshow.ppt
May 01, 2003 - Benefit of heparin use in central venous and pulmonary artery catheters: a meta-analysis of randomized
-
psnet.ahrq.gov/node/60722/psn-pdf
February 06, 2023 - This process has been described as “cognitive debiasing” or “meta-cognition.” … New York,10 and
4.3% in a large study from Seattle.28
According to a literature review and pooled analysis … nasopharyngeal sampling is more sensitive than oropharyngeal sampling.39,40 A recent systematic
review and meta-analysis … Detection and analysis of nucleic acid in various biological samples of
COVID-19 patients. … performance of different sampling approaches for
SARS-CoV-2 RT-PCR testing: a systematic review and meta-analysis
-
psnet.ahrq.gov/primer/failure-rescue
September 15, 2024 - The monitoring and analysis functions involved in recognizing and responding to such a challenge - or … accomplishing usual tasks - can be articulated using the Functional Resonance Analysis Method (FRAM) … FRAM: The Functional Resonance Analysis Method: Modelling Complex Socio-technical Systems (1st ed.). … illness scores and artificial intelligence models that are predictive of intensive care unit mortality: meta-analysis … Systematic review and longitudinal analysis of implementing Artificial Intelligence to predict clinical
-
psnet.ahrq.gov/web-mm/delayed-diagnosis-endocrinologic-emergencies
November 13, 2024 - Association between physician depressive symptoms and medical errors: A systematic review and meta-analysis … December 4, 2019
Influence of burnout on patient safety: systematic review and meta-analysis
-
psnet.ahrq.gov/web-mm/sick-and-pregnant
August 25, 2021 - August 7, 2024
Root cause analysis of cases involving diagnosis. … Surgeon's narcissism, hostility, stress, bullying, meaning in life and work environment: a two-centered analysis … Medication-related interventions delivered both in hospital and following discharge: a systematic review and meta-analysis … for Improving Patient Safety
March 29, 2023
ISMP medication error report analysis
-
psnet.ahrq.gov/node/49787/psn-pdf
March 01, 2017 - Lithium toxicity profile: a
systematic review and meta-analysis. Lancet. 2012;379:721-728. … HW, Mathews SC, et al. 25-year summary of US malpractice claims for
diagnostic errors 1986–2010: an analysis … systems affect thinking
Recognizing and compensating for system flaws
Openness to discussing error
Analysis … to external demands
"Cognitive autopsy" (chart-stimulated recall and narrative writing)
Root cause analysis
-
psnet.ahrq.gov/primer/strategies-improve-organizational-health-literacy
August 30, 2023 - The role of health literacy in diabetes knowledge, self-care, and glycemic control: a meta-analysis. … A Psychometric analysis of the Health Literate Healthcare Organization-10 Item Questionnaire.