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361. Effect of a multifaceted clinical pharmacist intervention on medication safety after hospitalization in persons prescribed high-risk medications: a randomized clinical trial. | PSNet
     psnet.ahrq.gov/issue/effect-multifaceted-clinical-pharmacist-intervention-medication-safety-after-hospitalization
     April 28, 2021 - 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.

362. 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.

363. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/846445/psn-pdf
     March 22, 2023 - https://psnet.ahrq.gov/issue/formalizing-hidden-curriculum-performance-enhancing-errors Error management … This commentary calls for increased use of EMT for surgical students and residents to promote error … formalizing-hidden-curriculum-performance-enhancing-errors https://psnet.ahrq.gov/issue/imperfect-practice-makes-perfect-error-management-training-improves-transfer-learning … https://psnet.ahrq.gov/issue/crisis-recovery-surgery-error-management-and-problem-solving-safety-critical-situations … https://psnet.ahrq.gov/issue/use-error-management-theory-quantify-and-characterize-residents-error-recovery-strategies

364. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47981/psn-pdf
     May 15, 2019 - Systematic error and cognitive bias in obstetric ultrasound. … Systematic error and cognitive bias in obstetric ultrasound. … https://psnet.ahrq.gov/issue/systematic-error-and-cognitive-bias-obstetric-ultrasound Cognitive biases … The authors review systemic factors that facilitate this type of error and suggest avenues for improvement … /issue/error-and-uncertainty-diagnostic-radiology https://psnet.ahrq.gov/web-mm/not-miscarriage https

365. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/74747/psn-pdf
     February 09, 2022 - Diagnostic error in the pediatric hospital: a narrative review. … Diagnostic error in the pediatric hospital: a narrative review. … https://psnet.ahrq.gov/issue/diagnostic-error-pediatric-hospital-narrative-review Diagnostic errors … Findings suggest that the prevalence of diagnostic error in pediatric hospitals varied and largely depended … https://psnet.ahrq.gov/issue/diagnostic-error-pediatric-hospital-narrative-review https://psnet.ahrq.gov

366. 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.

367. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50729/psn-pdf
     December 11, 2019 - Improving Diagnostic Quality & Safety/Reducing Diagnostic Error: Measurement Considerations. … https://psnet.ahrq.gov/issue/improving-diagnostic-quality-safetyreducing-diagnostic-error-measurement … This report updates an earlier environmental assessment on the validity and quality of diagnostic error … The authors also identified advancing the science of diagnostic error as an emerging area of focus. … https://psnet.ahrq.gov/issue/improving-diagnostic-quality-safetyreducing-diagnostic-error-measurement-considerations

368. 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/

369. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/837213/psn-pdf
     May 25, 2022 - Nurse Vaught sentenced for deadly medical error. May 25, 2022 DePeau-Wilson M. …   https://psnet.ahrq.gov/issue/nurse-vaught-sentenced-deadly-medical-error Disciplinary actions … This article summarizes reaction to the sentencing of a nurse in a high-profile medication error case … https://psnet.ahrq.gov/issue/nurse-vaught-sentenced-deadly-medical-error https://psnet.ahrq.gov/issue … /criminalization-human-error-and-guilty-verdict-travesty-justice-threatens-patient-safety https://psnet.ahrq.gov

370. Preparing your hospital for compliance with The Joint Commission's National Patient Safety Goals. | PSNet
     psnet.ahrq.gov/issue/preparing-your-hospital-compliance-joint-commissions-national-patient-safety-goals
     December 30, 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. … June 16, 2019 ISMP medication error report analysis.

371. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43981/psn-pdf
     April 22, 2015 - National Aeronautics and Space Administration "threat and error" model applied to pediatric cardiac … surgery: error cycles precede ? … surgery: error cycles precede ? … was used to analyze the incidence and types of error in pediatric cardiac surgery procedures. … whereby the effect of a single error was compounded by failure to rescue.

372. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35611/psn-pdf
     June 23, 2010 - Error or "act of God"? … Error or "act of God"? … https://psnet.ahrq.gov/issue/error-or-act-god-study-patients-and-operating-room-team-members- perceptions-error-definition … https://psnet.ahrq.gov/issue/error-or-act-god-study-patients-and-operating-room-team-members-perceptions-error-definition … https://psnet.ahrq.gov/issue/error-or-act-god-study-patients-and-operating-room-team-members-perceptions-error-definition

373. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42444/psn-pdf
     August 08, 2013 - The evolution of error: error management, cognitive constraints, and adaptive decision-making biases … The evolution of error: error management, cognitive constraints, and adaptive decision-making biases … https://psnet.ahrq.gov/issue/evolution-error-error-management-cognitive-constraints-and-adaptive-decision … https://psnet.ahrq.gov/issue/evolution-error-error-management-cognitive-constraints-and-adaptive-decision-making-biases … https://psnet.ahrq.gov/issue/evolution-error-error-management-cognitive-constraints-and-adaptive-decision-making-biases

374. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40922/psn-pdf
     December 21, 2014 - Assessment of latent factors contributing to error: addressing surgical pathology error wisely. … Assessment of Latent Factors Contributing to Error: Addressing Surgical Pathology Error Wisely. … https://psnet.ahrq.gov/issue/assessment-latent-factors-contributing-error-addressing-surgical-pathology … https://psnet.ahrq.gov/issue/assessment-latent-factors-contributing-error-addressing-surgical-pathology-error-wisely … https://psnet.ahrq.gov/issue/assessment-latent-factors-contributing-error-addressing-surgical-pathology-error-wisely

375. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35575/psn-pdf
     April 11, 2011 - Parental preferences for error disclosure, reporting, and legal action after medical error in the care … Parental preferences for error disclosure, reporting, and legal action after medical error in the care … desire full disclosure about a medical error. … https://psnet.ahrq.gov/issue/parental-preferences-error-disclosure-reporting-and-legal-action-after-medical-error-care … https://psnet.ahrq.gov/issue/parental-preferences-error-disclosure-reporting-and-legal-action-after-medical-error-care

376. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36784/psn-pdf
     February 24, 2011 - The many faces of error disclosure: a common set of elements and a definition. … The many faces of error disclosure: a common set of elements and a definition. … errors occur, patients desire full disclosure about the error and why it occurred.  … the error and the adverse clinical outcome, a phenomenon also noted in prior research.  … of the error as well as providing sufficient information to "connect the dots" between the error and

377. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43910/psn-pdf
     November 23, 2016 - Error disclosure and family members' reactions: does the type of error really matter? … Error disclosure and family members' reactions: does the type of error really matter? … https://psnet.ahrq.gov/issue/error-disclosure-and-family-members-reactions-does-type-error-really-matter … In this study, Italian physicians were videotaped in a simulated scenario of error disclosure to a … https://psnet.ahrq.gov/issue/error-disclosure-and-family-members-reactions-does-type-error-really-matter

378. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44657/psn-pdf
     November 11, 2015 - Understanding and confronting our mistakes: the epidemiology of error in radiology and strategies for … error reduction. … error reduction. … https://psnet.ahrq.gov/issue/understanding-and-confronting-our-mistakes-epidemiology-error-radiology-and-strategies-error … https://psnet.ahrq.gov/issue/understanding-and-confronting-our-mistakes-epidemiology-error-radiology-and-strategies-error

379. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34691/psn-pdf
     May 18, 2016 - Error in medicine. May 18, 2016 Leape L. Error in medicine. JAMA. 1994;272(23):1851-1857. … https://psnet.ahrq.gov/issue/error-medicine Leape discusses how traditional methods of error reduction … With reference to Reason, he briefly reviews the cognitive psychology of human error, distinguishing … between performance and error at the schematic or "skill" level, where an error is a "slip" (or "lapse … "), and at the rule-based or "knowledge" level, where an error is a "mistake."

380. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/841156/psn-pdf
     October 10, 2010 - “Those found responsible have been sacked”: some observations on the usefulness of error. … “Those found responsible have been sacked”: some observations on the usefulness of error. … https://psnet.ahrq.gov/issue/those-found-responsible-have-been-sacked-some-observations-usefulness- error … https://psnet.ahrq.gov/issue/new-view-human-error-origins-ambiguities-successes-and-critiques https: … /issue/human-error https://psnet.ahrq.gov/issue/role-error-organizing-behaviour