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1181. 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.

1182. 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

1183. 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

1184. 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.

1185. 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

1186. 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

1187. 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

1188. 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

1189. 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

1190. 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

1191. 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/

1192. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.218_slideshow.ppt
      May 01, 2010 - Spotlight Case [MONTH] 2003 Spotlight Case Fatal Error in Neonate: Does ‘Just Culture’ Provide an Answer … contributions to errors in care Identify best sources of information for designing a response to an error … * Case: Fatal Error in Neonate (3) Within 4 hours of starting the lipid emulsion through the TPN … The sequence of events and underlying reasons for the error were not investigated further. … Pellegrino E.D.: Prevention of medical error: Where professional and organizational ethics meet.

1193. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38433/psn-pdf
      February 25, 2009 - The impact of trained assistance on error rates in anaesthesia: a simulation-based randomised controlled … The impact of trained assistance on error rates in anaesthesia: a simulation-based randomised controlled … https://psnet.ahrq.gov/issue/impact-trained-assistance-error-rates-anaesthesia-simulation-based- randomised-controlled … This study used simulation-based training of anesthetists to demonstrate a reduction in error rates … https://psnet.ahrq.gov/issue/impact-trained-assistance-error-rates-anaesthesia-simulation-based-randomised-controlled

1194. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36198/psn-pdf
      March 28, 2011 - Using human error theory to explore the supply of non- prescription medicines from community pharmacies … Using human error theory to explore the supply of non- prescription medicines from community pharmacies … https://psnet.ahrq.gov/issue/using-human-error-theory-explore-supply-non-prescription-medicines- community-pharmacies … The authors applied human error theory to study consultations for over-the-counter medications in  … https://psnet.ahrq.gov/issue/using-human-error-theory-explore-supply-non-prescription-medicines-community-pharmacies

1195. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36630/psn-pdf
      January 05, 2017 - The VHA New England Medication Error Prevention Initiative as a model for long-term improvement collaboratives … The VHA New England Medication Error Prevention Initiative as a model for long-term improvement collaboratives … https://psnet.ahrq.gov/issue/vha-new-england-medication-error-prevention-initiative-model-long-term- … be most effective for organizations looking to address broad and complex goals such as medication error … https://psnet.ahrq.gov/issue/vha-new-england-medication-error-prevention-initiative-model-long-term-improvement

1196. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44093/psn-pdf
      April 29, 2015 - South Carolina medication error bill is dangerously off target. … https://psnet.ahrq.gov/issue/south-carolina-medication-error-bill-dangerously-target This newsletter … article reports on issues related to a legislation, drafted in response to a tenfold dosing error, … One particular concern highlighted is that the bill does not recognize the role of human error and systems … https://psnet.ahrq.gov/issue/south-carolina-medication-error-bill-dangerously-target https://psnet.ahrq.gov

1197. 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.

1198. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43844/psn-pdf
      January 21, 2015 - Unintended side effects: arbitration and the deterrence of medical error. … https://psnet.ahrq.gov/issue/unintended-side-effects-arbitration-and-deterrence-medical-error This commentary … explores the role of medical malpractice arbitration as a deterrent to medical error. … large health care system to recommend modifications in the arbitration process to prevent medical error … https://psnet.ahrq.gov/issue/unintended-side-effects-arbitration-and-deterrence-medical-error https:/

1199. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34658/psn-pdf
      March 07, 2005 - The role of error in organizing behaviour. March 7, 2005 Rasmussen J. … The role of error in organizing behaviour. Qual Saf Health Care. 2003;12(5):377-383. … https://psnet.ahrq.gov/issue/role-error-organizing-behaviour In this article, Rasmussen presents the … concept of human error, and how complex and dynamic environments should shift the focus of error. … https://psnet.ahrq.gov/issue/role-error-organizing-behaviour

1200. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46461/psn-pdf
      November 01, 2017 - Complications: acknowledging, managing, and coping with human error. … Complications: acknowledging, managing, and coping with human error. … https://psnet.ahrq.gov/issue/complications-acknowledging-managing-and-coping-human-error Human factors … This review explores reasons clinicians remain reluctant to disclose error, such as shame, insufficient … /issue/human-error-medicine https://psnet.ahrq.gov/primer/disclosure-errors https://psnet.ahrq.gov/issue