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381. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/61026/psn-pdf
     October 14, 2020 - A blinded, prospective study of error detection during physician chart rounds in radiation oncology. … A blinded, prospective study of error detection during physician chart rounds in radiation oncology. … https://psnet.ahrq.gov/issue/blinded-prospective-study-error-detection-during-physician-chart-rounds- … inserted these treatment plans into weekly chart rounds to assess the effectiveness of peer review on error … The authors suggest that error detection could be significantly improved by shortening chart rounds

382. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43419/psn-pdf
     October 20, 2014 - Impact of a reengineered electronic error-reporting system on medication event reporting and care process … Impact of a reengineered electronic error-reporting system on medication event reporting and care process … https://psnet.ahrq.gov/issue/impact-reengineered-electronic-error-reporting-system-medication-event- … This pre-post study sought to determine the impact of a reengineered medication error reporting approach … The intervention led to increased error reporting, with the majority of errors being near-misses.

383. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35409/psn-pdf
     September 11, 2009 - The Perruche case and the issue of compensation for the consequences of medical error. … The Perruche case and the issue of compensation for the consequences of medical error. … presents a high-profile French diagnostic error case and draws parallels from its resolution to the … U.S. debate on "just" compensation for patients and families affected by medical error. … psnet.ahrq.gov//#error

384. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36412/psn-pdf
     December 22, 2010 - Ambiguities of chronic illness management and challenges to the medical error paradigm. … Ambiguities of chronic illness management and challenges to the medical error paradigm. … https://psnet.ahrq.gov/issue/ambiguities-chronic-illness-management-and-challenges-medical-error- paradigm … The authors studied provider understanding of error in two diabetes clinics and found that medical … error vocabularies used in acute illness care are mismatched when used regarding chronic illness.

385. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35504/psn-pdf
     February 22, 2010 - Dispensing error rate in a highly automated mail-service pharmacy practice. … Dispensing error rate in a highly automated mail-service pharmacy practice. … authors found an error rate of less than 1 error per 1,000 prescriptions dispensed though a mail- service … pharmacy and conclude that the highly automated process contributed to the low rate of error. … https://psnet.ahrq.gov/issue/dispensing-error-rate-highly-automated-mail-service-pharmacy-practice

386. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/72526/psn-pdf
     January 01, 2021 - How effective are electronic medication systems in reducing medication error rates and associated harm … How effective are electronic medication systems in reducing medication error rates and associated harm … https://psnet.ahrq.gov/issue/how-effective-are-electronic-medication-systems-reducing-medication-error … review, the authors found variable evidence about the effectiveness of these systems for medication error … Included studies reported reductions in error rates, but implementation of electronic systems did not

387. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39863/psn-pdf
     January 04, 2011 - Improving the quality of drug error reporting. January 4, 2011 Armitage G, Newell R, Wright J. … Improving the quality of drug error reporting. … The authors make suggestions, based on error theory, to improve reporting systems to enhance the ease … of reporting and the quality of error reports. … https://psnet.ahrq.gov/issue/human-error

388. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73087/psn-pdf
     March 31, 2021 - Developing open disclosure strategies to medical error using simulation in final-year medical students … Developing open disclosure strategies to medical error using simulation in final-year medical students … https://psnet.ahrq.gov/issue/developing-open-disclosure-strategies-medical-error-using-simulation-final … students participating in a high-fidelity simulation session based on open disclosure after medication error … https://psnet.ahrq.gov/issue/developing-open-disclosure-strategies-medical-error-using-simulation-final-year-medical

389. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/848107/psn-pdf
     April 26, 2023 - with policy, procedures, and inefficient processes.3 The incidence of diagnostic error is not well … Recently, researchers and clinicians have debated methods for calculating error rates. … from human error continues to be studied. … to mitigate error are being developed and tested. … Diagnostic error in internal medicine. Arch Intern Med. 2005;165(13):1493-1499. 4.

390. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45595/psn-pdf
     April 19, 2017 - Estimating deaths due to medical error: the ongoing controversy and why it matters. … Estimating deaths due to medical error: the ongoing controversy and why it matters. … https://psnet.ahrq.gov/issue/estimating-deaths-due-medical-error-ongoing-controversy-and-why-it-matters … A recent article asserted that medical error is the third leading cause of death in the United States … The authors note that this estimate was generated by simply combining medical error rates from prior

391. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/837903/psn-pdf
     August 24, 2022 - The impact of drug error reduction software on preventing harmful adverse drug events in England: a … The impact of drug error reduction software on preventing harmful adverse drug events in England: a … https://psnet.ahrq.gov/issue/impact-drug-error-reduction-software-preventing-harmful-adverse-drug-events … In this study, dose error reduction software (DERS) was implemented across two large UK National Health … https://psnet.ahrq.gov/issue/impact-drug-error-reduction-software-preventing-harmful-adverse-drug-events-england

392. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34649/psn-pdf
     June 11, 2014 - On error management: lessons from aviation. June 11, 2014 Helmreich RL. … On error management: lessons from aviation. BMJ . 2000;320(7237):781-785. … https://psnet.ahrq.gov/issue/error-management-lessons-aviation In this perspective, the author draws … Helmreich provides background on the methods and use of error data in aviation, and how those processes … importance of reliable data on error, both of which are necessary if providers are to systematically

393. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41704/psn-pdf
     September 26, 2012 - The role of surgeon error in withdrawal of postoperative life support. … The role of surgeon error in withdrawal of postoperative life support. … https://psnet.ahrq.gov/issue/role-surgeon-error-withdrawal-postoperative-life-support Through the use … https://psnet.ahrq.gov/issue/role-surgeon-error-withdrawal-postoperative-life-support https://psnet.ahrq.gov … /issue/nature-human-error-implications-surgical-practice https://psnet.ahrq.gov/issue/nature-human-error-implications-surgical-practice

394. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/74838/psn-pdf
     February 16, 2022 - Overstating inpatient deaths due to medical error erodes trust in healthcare and the patient safety … Overstating inpatient deaths due to medical error erodes trust in healthcare and the patient safety … https://psnet.ahrq.gov/issue/overstating-inpatient-deaths-due-medical-error-erodes-trust-healthcare-and … overestimated, and that patient safety advocates should shift the focus from estimating deaths due to medical error … https://psnet.ahrq.gov/issue/overstating-inpatient-deaths-due-medical-error-erodes-trust-healthcare-and-patient-safety

395. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73315/psn-pdf
     May 26, 2021 - What contributes to diagnostic error or delay? … What contributes to diagnostic error or delay? … https://psnet.ahrq.gov/issue/what-contributes-diagnostic-error-or-delay-qualitative-exploration-across … conducted focus groups with key clinician stakeholders to determine factors that contribute to diagnostic error … https://psnet.ahrq.gov/issue/what-contributes-diagnostic-error-or-delay-qualitative-exploration-across-diverse-acute-care

396. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60911/psn-pdf
     September 16, 2020 - Prevalence and characterisation of diagnostic error among 7-day all-cause hospital medicine readmissions … Prevalence and characterisation of diagnostic error among 7-day all- cause hospital medicine readmissions … https://psnet.ahrq.gov/issue/prevalence-and-characterisation-diagnostic-error-among-7-day-all-cause- … Over a 12-month period, 5.6% of readmissions were found to contain at least one diagnostic error during … https://psnet.ahrq.gov/issue/diagnostic-error-emergency-department-learning-national-patient-safety-incident-report

397. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44143/psn-pdf
     April 15, 2016 - "First, know thyself": cognition and error in medicine. … "First, know thyself": cognition and error in medicine. … https://psnet.ahrq.gov/issue/first-know-thyself-cognition-and-error-medicine Cognition has been recognized … as a human factor that can contribute to medical error. … https://psnet.ahrq.gov/issue/first-know-thyself-cognition-and-error-medicine https://psnet.ahrq.gov/issue

398. Your attention please... designing effective warnings. | PSNet
     psnet.ahrq.gov/issue/your-attention-please-designing-effective-warnings
     March 14, 2023 - 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.

399. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/61057/psn-pdf
     October 28, 2020 - Improving Diagnostic Quality and Safety/Reducing Diagnostic Error: Measurement Considerations. … https://psnet.ahrq.gov/issue/improving-diagnostic-quality-and-safetyreducing-diagnostic-error- measurement-considerations … Process and Outcomes domain of the 2017 Measurement Framework  for measuring and improving diagnostic error … failures; information overload; and dismissed patients) reflecting high priority examples of diagnostic error … https://psnet.ahrq.gov/issue/improving-diagnostic-quality-and-safetyreducing-diagnostic-error-measurement-considerations

400. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/74177/psn-pdf
     January 01, 2022 - Harnessing event report data to identify diagnostic error during the COVID-19 pandemic. … Harnessing event report data to identify diagnostic error during the COVID- 19 pandemic. … https://psnet.ahrq.gov/issue/harnessing-event-report-data-identify-diagnostic-error-during-covid-19- … pandemic The COVID-19 pandemic has exacerbated existing challenges associated with diagnostic error … https://psnet.ahrq.gov/issue/harnessing-event-report-data-identify-diagnostic-error-during-covid-19-