Background Hospitals in various countries such as the Netherlands investigate and analyse
serious adverse events (SAEs) to learn from previous events and attempt to prevent …

Objective The aim of the study was to assess the effectiveness of a new methodological tool
for the identification of corrective and preventive actions (CAPAs) after root cause analysis of …

Methods Two simulation scenarios were created based on real-life AEs identified through
the hospital's Safety Reporting System. Scenario A involved an error of commission …

Background The aggregate root cause analysis (AggRCA) was designed to improve the
understanding of system vulnerabilities contributing to patient harm, including surgical …

Current practice in healthcare risk management is supported by many tools for risk
assessment (understanding problems), but none for risk control (solving problems). The …

Objective: To identify the extent to which the Homeland Security Exercise and Evaluation
Program's (HSEEP) After Action Report/Improvement Plan (AAR/IP) template was followed …

Background Computerized physician order entry (CPOE) in hospitals is widely considered to
be important for patient safety, but implementation is lagging behind and user satisfaction is …

Objective To describe the training undertaken by pharmacists employed in a pharmacist-led
information technology-based intervention study to reduce medication errors in primary care …

Background Root cause analysis (RCA) is widely used following healthcare serious
incidents, but does not necessarily lead to robust risk controls. This research aimed to …

FUNDAMENTO: A monitoração dos indicadores de qualidade no cuidado com a saúde
(IQS) é um processo de fundamental importância na atenção à saúde dos pacientes …