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1101. A crack in our best armor: "wrong patient" injections from insulin pens alarmingly frequent even with barcode scanning. | PSNet
      psnet.ahrq.gov/issue/crack-our-best-armor-wrong-patient-injections-insulin-pens-alarmingly-frequent-even-barcode
      October 22, 2014 - June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … May 29, 2019 ISMP medication error report analysis.

1102. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42491/psn-pdf
      September 18, 2013 - The incidence of diagnostic error in medicine. September 18, 2013 Graber ML. … The incidence of diagnostic error in medicine. BMJ Qual Saf. 2013;22 Suppl 2:ii21-ii27. … https://psnet.ahrq.gov/issue/incidence-diagnostic-error-medicine This review examines eight research … methods used to estimate the incidence of diagnostic error and recommends tactics to improve its measurement … https://psnet.ahrq.gov/issue/incidence-diagnostic-error-medicine https://psnet.ahrq.gov/issue/overconfidence-cause-diagnostic-error-medicine

1103. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36011/psn-pdf
      September 24, 2010 - Geometric probability distribution for modeling of error risk during prescription dispensing. … Geometric probability distribution for modeling of error risk during prescription dispensing. … https://psnet.ahrq.gov/issue/geometric-probability-distribution-modeling-error-risk-during-prescription … dispensing Investigators observed pharmacy staff to determine the probability of at least one dispensing error … https://psnet.ahrq.gov/issue/geometric-probability-distribution-modeling-error-risk-during-prescription-dispensing

1104. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37292/psn-pdf
      May 24, 2015 - Guilty, afraid, and alone — struggling with medical error. May 24, 2015 Delbanco T, Bell SK. … Guilty, afraid, and alone--struggling with medical error. N Engl J Med. 2007;357(17):1682-3. … https://psnet.ahrq.gov/issue/guilty-afraid-and-alone-struggling-medical-error Disclosure of medical … An AHRQ WebM&M commentary, perspective, and interview also discuss multiple facets of error disclosure … https://psnet.ahrq.gov/issue/guilty-afraid-and-alone-struggling-medical-error https://psnet.ahrq.gov/

1105. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38814/psn-pdf
      July 29, 2009 - Pediatric vaccination errors: application of the "5 rights" framework to a national error reporting … Pediatric vaccination errors: application of the "5 rights" framework to a national error reporting … https://psnet.ahrq.gov/issue/pediatric-vaccination-errors-application-5-rights-framework-national-error … - reporting-database This study analyzed more than 600 pediatric vaccination error reports from MEDMARX … https://psnet.ahrq.gov/issue/pediatric-vaccination-errors-application-5-rights-framework-national-error-reporting-database

1106. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45834/psn-pdf
      February 22, 2017 - Implementing an error disclosure coaching model: a multicenter case study. … Implementing an error disclosure coaching model: A multicenter case study. … https://psnet.ahrq.gov/issue/implementing-error-disclosure-coaching-model-multicenter-case-study This … study described a demonstration project to enhance error disclosure. … ://psnet.ahrq.gov/primer/disclosure-errors https://psnet.ahrq.gov/issue/medical-error-second-victim

1107. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40527/psn-pdf
      June 15, 2011 - Online medication error graphic reports: a pilot in North Carolina nursing homes. … Online medication error graphic reports: a pilot in North Carolina nursing homes. … https://psnet.ahrq.gov/issue/online-medication-error-graphic-reports-pilot-north-carolina-nursing-homes … All North Carolina nursing homes are required to report medication error data. … This study reports on a pilot effort to feed back data on error rates to individual nursing homes.

1108. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35700/psn-pdf
      February 15, 2010 - Point-of-care testing error: sources and amplifiers, taxonomy, prevention strategies, and detection … Point-of-care testing error: sources and amplifiers, taxonomy, prevention strategies, and detection … https://psnet.ahrq.gov/issue/point-care-testing-error-sources-and-amplifiers-taxonomy-prevention- strategies-and-detection … They provide several strategies for error reduction. … https://psnet.ahrq.gov/issue/point-care-testing-error-sources-and-amplifiers-taxonomy-prevention-strategies-and-detection

1109. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44986/psn-pdf
      April 20, 2016 - Nurses' role in medical error recovery: an integrative review. … Nurses' role in medical error recovery: an integrative review. … https://psnet.ahrq.gov/issue/nurses-role-medical-error-recovery-integrative-review This review examined … According to some studies, nurses may recover as many as one error each shift. … A strong safety culture was an important organizational enabler of effective error recovery.

1110. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39595/psn-pdf
      June 15, 2011 - Application of human error theory in case analysis of wrong procedures. June 15, 2011 Duthie EA. … Application of Human Error Theory in Case Analysis of Wrong Procedures. … https://psnet.ahrq.gov/issue/application-human-error-theory-case-analysis-wrong-procedures This study … examines five wrong-procedure cases by applying James Reason’s human error theory, and describes the … /issue/human-error https://psnet.ahrq.gov/primer/systems-approach

1111. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35419/psn-pdf
      February 15, 2010 - College of American Pathologists Special Topic Symposium on Error in Pathology and Laboratory Medicine—Practical … https://psnet.ahrq.gov/issue/college-american-pathologists-special-topic-symposium-error-pathology-and … laboratory-medicine This issue section includes presentations from the September 2004 symposium on error … Topics covered include insurance issues, pathology databases, and general pathology and lab error reduction … https://psnet.ahrq.gov/issue/college-american-pathologists-special-topic-symposium-error-pathology-and-laboratory-medicine

1112. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40083/psn-pdf
      December 15, 2010 - Nighttime and weekend medication error rates in an inpatient pediatric population. … Nighttime and weekend medication error rates in an inpatient pediatric population. … https://psnet.ahrq.gov/issue/nighttime-and-weekend-medication-error-rates-inpatient-pediatric-population … This study found an increase in medication error rates during evening, nighttime, and weekend shifts … Medication administration and dispensing were the most common error types noted.

1113. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36782/psn-pdf
      August 26, 2011 - A review of medical error reporting system design considerations and a proposed cross-level systems … A review of medical error reporting system design considerations and a proposed cross-level systems … https://psnet.ahrq.gov/issue/review-medical-error-reporting-system-design-considerations-and-proposed … - cross-level-systems The authors review the literature on medical error reporting systems and propose … https://psnet.ahrq.gov/issue/review-medical-error-reporting-system-design-considerations-and-proposed-cross-level-systems

1114. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40843/psn-pdf
      October 12, 2011 - Error rates in breast imaging reports: comparison of automatic speech recognition and dictation transcription … Error rates in breast imaging reports: comparison of automatic speech recognition and dictation transcription … https://psnet.ahrq.gov/issue/error-rates-breast-imaging-reports-comparison-automatic-speech-recognition … - and-dictation Dictated radiology reports were far more likely to contain a major error if transcribed … https://psnet.ahrq.gov/issue/error-rates-breast-imaging-reports-comparison-automatic-speech-recognition-and-dictation

1115. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45338/psn-pdf
      July 20, 2016 - Understanding models of error and how they apply in clinical practice. … https://psnet.ahrq.gov/issue/understanding-models-error-and-how-they-apply-clinical-practice Human error … This commentary summarizes core concepts of human error and discusses how they can be applied to promote … https://psnet.ahrq.gov/issue/understanding-models-error-and-how-they-apply-clinical-practice https:// … psnet.ahrq.gov/issue/human-error-models-and-management https://psnet.ahrq.gov/perspective/count-and-be-counted-preparing-future-pharmacists-promote-culture-safety

1116. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44040/psn-pdf
      August 02, 2015 - why-physicians-err-diagnosis This previously published commentary provides a historical glimpse into diagnostic error … The piece discusses the value of autopsy in uncovering incorrect diagnoses, suggests that physician error … be classified as either social or clinical in nature, and explores factors that contribute to error … https://psnet.ahrq.gov/issue/cognitive-interventions-reduce-diagnostic-error-narrative-review https: … //psnet.ahrq.gov/issue/autopsy-advocates https://psnet.ahrq.gov/issue/human-error

1117. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40788/psn-pdf
      September 21, 2011 - Not overstepping professional boundaries: the challenging role of nurses in simulated error disclosures … Not overstepping professional boundaries: the challenging role of nurses in simulated error disclosures … //psnet.ahrq.gov/issue/not-overstepping-professional-boundaries-challenging-role-nurses-simulated- error-disclosures … This study revealed that nurses perceived their role in team-based error disclosure as secondary to … https://psnet.ahrq.gov/issue/not-overstepping-professional-boundaries-challenging-role-nurses-simulated-error-disclosures

1118. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40556/psn-pdf
      June 29, 2011 - A review of medical error taxonomies: a human factors perspective. … A review of medical error taxonomies: A human factors perspective. … https://psnet.ahrq.gov/issue/review-medical-error-taxonomies-human-factors-perspective This review compared … 26 medical error taxonomies using a human factors perspective and demonstrated that each taxonomy provides … highlight the importance of taxonomies that use knowledge of cognitive mechanisms and theoretical error

1119. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46685/psn-pdf
      January 17, 2018 - Insulin dosing error in a patient with severe hyperkalemia. … Insulin Dosing Error in a Patient With Severe Hyperkalemia. … https://psnet.ahrq.gov/issue/insulin-dosing-error-patient-severe-hyperkalemia This case report describes … an insulin dosing error during hospitalization. … https://psnet.ahrq.gov/issue/insulin-dosing-error-patient-severe-hyperkalemia https://psnet.ahrq.gov/

1120. Common cause analysis. | PSNet
      psnet.ahrq.gov/issue/common-cause-analysis
      June 27, 2018 - June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … June 16, 2019 ISMP medication error report analysis. … May 7, 2018 ISMP medication error report analysis.