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401. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44262/psn-pdf
     November 17, 2016 - The challenges in defining and measuring diagnostic error. November 17, 2016 Zwaan L, Singh H. … The challenges in defining and measuring diagnostic error. … https://psnet.ahrq.gov/issue/challenges-defining-and-measuring-diagnostic-error Although diagnostic … error is gaining attention, there is still lack of agreement on how to define and measure it. … https://psnet.ahrq.gov/issue/challenges-defining-and-measuring-diagnostic-error https://psnet.ahrq.gov

402. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34789/psn-pdf
     December 23, 2008 - Medication error prevention by pharmacists. … Medication error prevention by pharmacists. Am J Hosp Pharm. 1988;45(9):1902-3. … https://psnet.ahrq.gov/issue/medication-error-prevention-pharmacists This study investigated the impact … Physicians confirmed an error in more than 90% of orders questioned by pharmacists. … https://psnet.ahrq.gov/issue/medication-error-prevention-pharmacists

403. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50576/psn-pdf
     October 23, 2019 - Breakdowns in the initial patient-provider encounter are a frequent source of diagnostic error among … Breakdowns in the initial patient-provider encounter are a frequent source of diagnostic error among … psnet.ahrq.gov/issue/breakdowns-initial-patient-provider-encounter-are-frequent-source-diagnostic- error-among … presents with non-specific symptoms and requires time-sensitive treatment, can be a source of diagnostic error … https://psnet.ahrq.gov/issue/diagnostic-error-stroke-reasons-and-proposed-solutions

404. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40129/psn-pdf
     January 12, 2011 - Medical error disclosure training: evidence for values- based ethical environments. … Medical Error Disclosure Training: Evidence for Values-Based Ethical Environments. … https://psnet.ahrq.gov/issue/medical-error-disclosure-training-evidence-values-based-ethical-environments … inhibit clinicians from disclosing medical errors to patients, ranging from inadequate training in error … Based on survey data, the authors argue that formal error disclosure training programs for staff not

405. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41279/psn-pdf
     September 19, 2016 - Medical error, incident investigation and the second victim: doing better but feeling worse? … Medical error, incident investigation and the second victim: doing better but feeling worse? … https://psnet.ahrq.gov/issue/medical-error-incident-investigation-and-second-victim-doing-better-feeling … physicians-in-training and provides tactics to improve support for clinicians affected by medical error … https://psnet.ahrq.gov/issue/medical-error-second-victim

406. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36362/psn-pdf
     October 27, 2010 - Effectiveness of Toyota process redesign in reducing thyroid gland fine-needle aspiration error. … Effectiveness of Toyota process redesign in reducing thyroid gland fine-needle aspiration error. … psnet.ahrq.gov/issue/effectiveness-toyota-process-redesign-reducing-thyroid-gland-fine-needle- aspiration-error … The authors compared the frequency of diagnostic error for a thyroid aspiration service before and … after applying error reduction strategies.

407. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35797/psn-pdf
     May 24, 2010 - Medical error identification, disclosure, and reporting: do emergency medicine provider groups differ … Medical error identification, disclosure, and reporting: do emergency medicine provider groups differ … https://psnet.ahrq.gov/issue/medical-error-identification-disclosure-and-reporting-do-emergency-medicine … investigators had physicians, nurses, and emergency medical technicians review 10 vignettes illustrating error … They found variances between the three groups in identification of error and the likelihood of disclosure

408. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46293/psn-pdf
     January 01, 2021 - Development of the barriers to error disclosure assessment tool. … Development of the Barriers to Error Disclosure Assessment Tool. … https://psnet.ahrq.gov/issue/development-barriers-error-disclosure-assessment-tool Numerous factors … this study, researchers describe the development and validation of a tool to identify barriers to error … https://psnet.ahrq.gov/issue/development-barriers-error-disclosure-assessment-tool https://psnet.ahrq.gov

409. It is time to define antimicrobial never events. | PSNet
     psnet.ahrq.gov/issue/it-time-define-antimicrobial-never-events
     November 16, 2022 - 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.

410. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36738/psn-pdf
     August 02, 2011 - Barriers and motivators for making error reports from family medicine offices: a report from the American … Barriers and motivators for making error reports from family medicine offices: a report from the American … https://psnet.ahrq.gov/issue/barriers-and-motivators-making-error-reports-family-medicine-offices-report … - american-academy While incident reporting is an accepted method of error detection in the inpatient … , researchers conducted focus groups with physicians, nurses, and office staff around the issue of error

411. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/838249/psn-pdf
     October 05, 2022 - Rooting an error review process in just culture: lessons learned. … Rooting an error review process in just culture: lessons learned. … https://psnet.ahrq.gov/issue/rooting-error-review-process-just-culture-lessons-learned Shifting to a … nonpunitive approach to adverse events can improve error reporting and the overall safety culture. … of the hospital’s incident reporting system and outlines how those findings informed changes to the error

412. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47311/psn-pdf
     October 10, 2018 - Cognitive error in an academic emergency department. … Cognitive error in an academic emergency department. … https://psnet.ahrq.gov/issue/cognitive-error-academic-emergency-department In 2015, the National Academy … of Medicine called for renewed focus on reducing diagnostic error. … https://psnet.ahrq.gov/issue/cognitive-error-academic-emergency-department https://psnet.ahrq.gov/issue

413. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44900/psn-pdf
     April 22, 2016 - When a surgical colleague makes an error. April 22, 2016 Antiel RM, Blinman TA, Rentea RM, et al. … When a Surgical Colleague Makes an Error. … https://psnet.ahrq.gov/issue/when-surgical-colleague-makes-error Physicians have become more comfortable … recognizing and disclosing errors to patients in the past few decades, but speaking up about a peer's error … https://psnet.ahrq.gov/web-mm/duty-disclose-someone-elses-error

414. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47936/psn-pdf
     June 14, 2019 - A team disclosure of error educational activity: objective outcomes. … A Team Disclosure of Error Educational Activity: Objective Outcomes. … https://psnet.ahrq.gov/issue/team-disclosure-error-educational-activity-objective-outcomes Open disclosure … development and impact of an educational program using simulation to promote learning regarding team-based error … https://psnet.ahrq.gov/issue/team-disclosure-error-educational-activity-objective-outcomes https://psnet.ahrq.gov

415. Drug related admissions to a cardiology department; frequency and avoidability. | PSNet
     psnet.ahrq.gov/issue/drug-related-admissions-cardiology-department-frequency-and-avoidability
     August 20, 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. … June 16, 2019 ISMP medication error report analysis.

416. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46330/psn-pdf
     September 24, 2017 - Systemic error in radiology. September 24, 2017 Waite S, Scott JM, Legasto A, et al. … Systemic Error in Radiology. AJR Am J Roentgenol. 2017;209(3):629- 639. doi:10.2214/AJR.16.17719. … https://psnet.ahrq.gov/issue/systemic-error-radiology Radiology interpretation errors can contribute … to diagnostic error. … fool-me-twice-delayed-diagnoses-radiology-emphasis-perpetuated-errors https://psnet.ahrq.gov/issue/understanding-and-confronting-our-mistakes-epidemiology-error-radiology-and-strategies-error

417. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43239/psn-pdf
     June 11, 2014 - A cycle of redemption in a medical error disclosure and apology program. … A Cycle of Redemption in a Medical Error Disclosure and Apology Program. … https://psnet.ahrq.gov/issue/cycle-redemption-medical-error-disclosure-and-apology-program Clinicians … who are involved in a medical error and experience considerable emotional distress, shame, and self-doubt … program to determine the emotional process physicians undergo after committing and disclosing a medical error

418. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41392/psn-pdf
     July 02, 2014 - Exploring error in team-based acute care scenarios: an observational study from the United Kingdom. … Exploring error in team-based acute care scenarios: an observational study from the United kingdom. … https://psnet.ahrq.gov/issue/exploring-error-team-based-acute-care-scenarios-observational-study-united … - kingdom This study used an error-modeling system initially devised by Dr. … https://psnet.ahrq.gov/issue/human-error

419. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37722/psn-pdf
     February 18, 2011 - Leveraging computerized sign-out to increase error reporting and addressing patient safety in graduate … Leveraging computerized sign-out to increase error reporting and addressing patient safety in graduate … https://psnet.ahrq.gov/issue/leveraging-computerized-sign-out-increase-error-reporting-and-addressing … - patient-safety An error reporting system linked to the electronic patient sign-out system significantly … increased error reporting rates by internal medicine residents.

420. 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