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2721. 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

2722. 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

2723. National Patient Safety Goals. | PSNet
      psnet.ahrq.gov/issue/national-patient-safety-goals
      May 30, 2012 - 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.

2724. Preventing harm from high-alert medications. | PSNet
      psnet.ahrq.gov/issue/preventing-harm-high-alert-medications
      August 14, 2017 - 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.

2725. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/47378/psn-pdf
      February 22, 2019 - Taking the blame: appropriate responses to medical error. February 22, 2019 Tigard DW. … Taking the blame: appropriate responses to medical error. J Med Ethics. 2019;45(2):101-105. … https://psnet.ahrq.gov/issue/taking-blame-appropriate-responses-medical-error Balancing between explicit … calls for accountability for error and constructive discussion of mistakes in health care is challenging … https://psnet.ahrq.gov/issue/taking-blame-appropriate-responses-medical-error https://psnet.ahrq.gov/

2726. 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

2727. 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

2728. 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

2729. 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

2730. 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

2731. 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:/

2732. 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

2733. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43648/psn-pdf
      November 21, 2016 - Patient- and family-centered care: error disclosure and investigation. … https://psnet.ahrq.gov/issue/patient-and-family-centered-care-error-disclosure-and-investigation Patients … Describing a near miss of a medication error, this magazine article examines elements of effective disclosure … and how engaging patients and their families can contribute to error investigations and safety improvement … https://psnet.ahrq.gov/issue/patient-and-family-centered-care-error-disclosure-and-investigation https

2734. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42635/psn-pdf
      December 06, 2013 - Improving disclosure and management of medical error—an opportunity to transform the surgeons of tomorrow … Improving disclosure and management of medical error - an opportunity to transform the surgeons of tomorrow … https://psnet.ahrq.gov/issue/improving-disclosure-and-management-medical-error-opportunity-transform- … surgeons-tomorrow This review recommends educating surgical trainees about error disclosure, teamwork … https://psnet.ahrq.gov/issue/improving-disclosure-and-management-medical-error-opportunity-transform-surgeons-tomorrow

2735. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/42314/psn-pdf
      May 19, 2014 - "Apologies" for pathologists: why, when, and how to say "sorry" after committing a medical error. … "Apologies" from pathologists: why, when, and how to say "sorry" after committing a medical error. … //psnet.ahrq.gov/issue/apologies-pathologists-why-when-and-how-say-sorry-after-committing-medical- error … This commentary explores how apologies and error disclosure are challenging for pathologists, due to … https://psnet.ahrq.gov/issue/apologies-pathologists-why-when-and-how-say-sorry-after-committing-medical-error

2736. Improving insulin distribution and administration safety using Lean Six Sigma methodologies. | PSNet
      psnet.ahrq.gov/issue/improving-insulin-distribution-and-administration-safety-using-lean-six-sigma-methodologies
      March 19, 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.

2737. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40784/psn-pdf
      September 21, 2011 - Do remote community telepharmacies have higher medication error rates than traditional community pharmacies … Do remote community telepharmacies have higher medication error rates than traditional community pharmacies … https://psnet.ahrq.gov/issue/do-remote-community-telepharmacies-have-higher-medication-error-rates- … traditional-community This study reported a lower overall medication error rate for telepharmacy sites … https://psnet.ahrq.gov/issue/do-remote-community-telepharmacies-have-higher-medication-error-rates-traditional-community

2738. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36107/psn-pdf
      September 28, 2010 - The "Big Dog" effect: variability assessing the causes of error in diagnoses of patients with lung cancer … The "Big Dog" effect: variability assessing the causes of error in diagnoses of patients with lung cancer … https://psnet.ahrq.gov/issue/big-dog-effect-variability-assessing-causes-error-diagnoses-patients-lung … false-negative diagnostic results and found poor agreement among pathologists as to the causes of the error … https://psnet.ahrq.gov/issue/big-dog-effect-variability-assessing-causes-error-diagnoses-patients-lung-cancer

2739. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36224/psn-pdf
      October 19, 2010 - Nonpunitive medication error reporting: 3-year findings from one hospital's primum non nocere initiative … Nonpunitive medication error reporting: 3-year findings from one hospital's Primum Non Nocere initiative … https://psnet.ahrq.gov/issue/nonpunitive-medication-error-reporting-3-year-findings-one-hospitals-primum … non-nocere The investigators conducted a survey to inform the implementation of a nonpunitive medication error … https://psnet.ahrq.gov/issue/nonpunitive-medication-error-reporting-3-year-findings-one-hospitals-primum-non-nocere

2740. 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.