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3521. 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

3522. 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

3523. 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:/

3524. 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

3525. 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.

3526. 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.

3527. 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

3528. 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

3529. 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

3530. 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

3531. 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

3532. 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

3533. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/49624/psn-pdf
      May 01, 2011 - Describe key principles in effective error disclosure. … the error, fears of retaliation can ensue. … If they determined that a clear error occurred, providers should have found a way to disclose the error … If other providers have committed an error, optimal strategies involve full collaboration in error investigation … and joint disclosure if an error did occur.

3534. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43620/psn-pdf
      October 29, 2014 - Error in intensive care: psychological repercussions and defense mechanisms among health professionals … Error in intensive care: psychological repercussions and defense mechanisms among health professionals … https://psnet.ahrq.gov/issue/error-intensive-care-psychological-repercussions-and-defense-mechanisms- … https://psnet.ahrq.gov/issue/error-intensive-care-psychological-repercussions-and-defense-mechanisms-among-health … https://psnet.ahrq.gov/issue/error-intensive-care-psychological-repercussions-and-defense-mechanisms-among-health

3535. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45383/psn-pdf
      August 31, 2016 - Case report of a medication error: in the eye of the beholder. … Case report of a medication error. … https://psnet.ahrq.gov/issue/case-report-medication-error-eye-beholder Look-alike drug names or packaging … This case discussion reviews an error in the community setting involving a nonocular medication mistakenly … https://psnet.ahrq.gov/issue/case-report-medication-error-eye-beholder https://psnet.ahrq.gov/issue/drug-labeling-and-packaging-looking-beyond-what-meets-eye

3536. 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.

3537. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45520/psn-pdf
      October 05, 2016 - Defining excellence: next steps for practicing clinicians seeking to prevent diagnostic error. … Defining excellence: next steps for practicing clinicians seeking to prevent diagnostic error. … psnet.ahrq.gov/issue/defining-excellence-next-steps-practicing-clinicians-seeking-prevent- diagnostic-error … Discussing the impact of diagnostic error on practicing physicians, this commentary employs case analysis … psnet.ahrq.gov/issue/defining-excellence-next-steps-practicing-clinicians-seeking-prevent-diagnostic-error

3538. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46741/psn-pdf
      June 07, 2018 - Suffering in silence: medical error and its impact on health care providers. … Suffering in Silence: Medical Error and its Impact on Health Care Providers. … https://psnet.ahrq.gov/issue/suffering-silence-medical-error-and-its-impact-health-care-providers Involvement … This review describes negative emotions clinicians may experience after an error, such as guilt, shame … https://psnet.ahrq.gov/issue/suffering-silence-medical-error-and-its-impact-health-care-providers https

3539. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/41751/psn-pdf
      October 24, 2012 - Diet order entry by registered dietitians results in a reduction in error rates and time delays compared … Diet order entry by registered dietitians results in a reduction in error rates and time delays compared … https://psnet.ahrq.gov/issue/diet-order-entry-registered-dietitians-results-reduction-error-rates-and-time … directly enter physician cosigned diet orders for patients significantly decreased nutrition-related error … https://psnet.ahrq.gov/issue/diet-order-entry-registered-dietitians-results-reduction-error-rates-and-time-delays-compared

3540. 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.