Learning from preventable deaths: exploring case record reviewers' narratives using change analysis.
Hogan H, Healey F, Neale G, Thomson R, Black N, Vincent C. J R Soc Med. 2014;107:365-375.
Researchers applied change analysis, a type of root cause analysis, to their review of preventable deaths. This method reliably identified contributing factors and enabled more in-depth understanding about underlying problems related to care processes, lending support to utilizing this approach to characterize adverse events and near misses.
Causes of medication administration errors in hospitals: a systematic review of quantitative and qualitative evidence.
Keers RN, Williams SD, Cooke J, Ashcroft DM. Drug Saf. 2013;36:1045-1067.
Patient safety: threats and solutions.
McCaughan D, Kaufman G. Nurs Stand. 2013;27:48-55.
Suicide attempts and completions on medical-surgical and intensive care units.
Mills PD, Watts BV, Hemphill RR. J Hosp Med. 2014;9:182-185.
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National Patient Safety Alerting System.