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1381. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36127/psn-pdf
      September 29, 2010 - Fatality involving vinblastine overdose as a result of a complex medical error. … Fatality involving vinblastine overdose as a result of a complex medical error. … https://psnet.ahrq.gov/issue/fatality-involving-vinblastine-overdose-result-complex-medical-error The … authors investigated a fatal chemotherapy-related error and identified contributing factors that led … ://psnet.ahrq.gov//#error

1382. 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.

1383. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35401/psn-pdf
      April 06, 2011 - What constitutes a prescribing error in paediatrics? … What constitutes a prescribing error in paediatrics? Qual Saf Health Care. 2005;14(5):352-7. … https://psnet.ahrq.gov/issue/what-constitutes-prescribing-error-paediatrics The authors used a Delphi … technique to gather expert opinion on what constitutes a prescribing error in pediatrics. … https://psnet.ahrq.gov/issue/what-constitutes-prescribing-error-paediatrics

1384. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43272/psn-pdf
      June 18, 2014 - Physician assistants and the disclosure of medical error. … Physician assistants and the disclosure of medical error. … https://psnet.ahrq.gov/issue/physician-assistants-and-disclosure-medical-error Most existing evidence … and guidelines for error disclosure are modeled around physicians, nurses, and risk managers. … https://psnet.ahrq.gov/issue/physician-assistants-and-disclosure-medical-error https://psnet.ahrq.gov

1385. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42228/psn-pdf
      October 08, 2013 - Cognitive diagnostic error in internal medicine. October 8, 2013 Van den Berge K, Mamede S. … Cognitive diagnostic error in internal medicine. … https://psnet.ahrq.gov/issue/cognitive-diagnostic-error-internal-medicine This review discusses how … confirmation bias and availability bias can contribute to diagnostic error and highlights the need for … https://psnet.ahrq.gov/issue/cognitive-diagnostic-error-internal-medicine https://psnet.ahrq.gov/issue

1386. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49552/psn-pdf
      January 01, 2008 - Understand coping strategies, including error disclosure. … is difficult, although 2 factors related to the error itself have been proposed. … felt for the error. … The resident was devastated by the error. … Medical error: the second victim. The doctor who makes the mistake needs help too.

1387. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39723/psn-pdf
      February 01, 2011 - Barriers and facilitators to chemotherapy patients' engagement in medical error prevention. … Barriers and facilitators to chemotherapy patients' engagement in medical error prevention. … https://psnet.ahrq.gov/issue/barriers-and-facilitators-chemotherapy-patients-engagement-medical-error … - prevention This study found that patients are engaged in error prevention but perceive considerable … https://psnet.ahrq.gov/issue/barriers-and-facilitators-chemotherapy-patients-engagement-medical-error-prevention

1388. 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/

1389. Dealing honestly with an honest mistake. | PSNet
      psnet.ahrq.gov/issue/dealing-honestly-honest-mistake
      March 24, 2019 - 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. … June 16, 2019 ISMP medication error report analysis.

1390. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/37095/psn-pdf
      September 04, 2010 - Prospective error recording in surgery: an analysis of 1108 elective neurosurgical cases. … Prospective error recording in surgery: an analysis of 1108 elective neurosurgical cases. … https://psnet.ahrq.gov/issue/prospective-error-recording-surgery-analysis-1108-elective-neurosurgical … frequently, most were preventable, and 2.7% of patients experienced an adverse clinical outcome due to error … https://psnet.ahrq.gov/issue/prospective-error-recording-surgery-analysis-1108-elective-neurosurgical-cases

1391. 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

1392. 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

1393. 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

1394. 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.

1395. In response to “Getting to the Root of the Matter” (June 2005) | PSNet
      psnet.ahrq.gov/perspective/response-getting-root-matter-june-2005
      June 01, 2005 - While they do mention conducting "interviews with key staff involved in the error," they do not propose … My interpretation is that this includes those directly involved in the error. … Williams suggests that individuals directly involved in an error should participate in the root cause … can have a hard time separating themselves from the error and focusing on systems solutions. … The viewpoint of the health care provider involved in an error, however, is critical.

1396. 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

1397. 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.

1398. Spotlight Case [MONTH] 2003 (ppt file)
      psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.167_slideshow.ppt
      January 01, 2008 - responsibility felt for the error If provider feels directly and fully responsible, error will be more … The resident was devastated by the error. … Helping clincians find resolution after a medical error. … Helping clincians find resolution after a medical error. … Helping clincians find resolution after a medical error.

1399. 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

1400. ISMP's Guidelines for Standard Order Sets. | PSNet
      psnet.ahrq.gov/issue/ismps-guidelines-standard-order-sets
      May 11, 2017 - July 10, 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. … June 16, 2019 ISMP medication error report analysis.