{1}
##LOC[OK]##
{1}
##LOC[OK]##
##LOC[Cancel]##
{1}
##LOC[OK]##
##LOC[Cancel]##
Skip Navigation
www.ahrq.gov
search
home
whatsnew
collection
primers
glossary
newsletter
mypsnet
newsletter
The Collection
>
Getting to the Root of the Matter
Flanders SA, Saint S. AHRQ WebM&M [serial online]. June 2005.
Using a case of a dosing error, the authors describe the best practices in performing a root cause analysis.
Free full text
Related Resources
COMMENTARY
Intubation Mishap.
Weinger MB, Blike GT. AHRQ WebM&M [serial online]. September 2003.
ORGANIZATIONAL POLICY/GUIDELINES
Preventing vincristine administration errors.
The Joint Commission. Sentinel Event Alert. July 14, 2005;(34):1-3.
COMMENTARY
Not again!
Berwick DM. BMJ. 2001;322:247-248.
COMMENTARY
Novel Drug Misuse.
Angus DC, Milbrandt EB. AHRQ WebM&M [serial online]. July 2004.
View all related resources...
Download:
Adobe Reader
Email
Find Related Resources by...
Resource Type
Commentary
Setting of Care
Intensive Care Units
Emergency Departments
Target Audience
Physicians
Nurses
Pharmacists
Clinical Area
Critical Care
Safety Target
Ordering/Prescribing Errors
Administration Errors
Error Types
Noncognitive Errors ("Slips & Lapses")
Cognitive Errors ("Mistakes")
Approach to Improving Safety
Root Cause Analysis
Read Back Protocols
Technologic Approaches