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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43983/psn-pdf
    February 05, 2016 - Near-miss transcription errors: a comparison of reporting rates between a novel error-reporting mechanism … Near-miss transcription errors: a comparison of reporting rates between a novel error-reporting mechanism … This observational study compared error detection rates for medication transcription errors between … a hospital's formal reporting system and a passive error identification mechanism embedded in ordering … reporting mechanism identified fewer errors than electronic surveillance, emphasizing the need to build error
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34126/psn-pdf
    July 20, 2012 - National Coordinating Council for Medication Error Reporting and Prevention. … July 20, 2012 National Coordinating Council for Medication Error Reporting and Prevention. … https://psnet.ahrq.gov/issue/national-coordinating-council-medication-error-reporting-and-prevention … National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) coordinates a … medication error.
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49527/psn-pdf
    December 01, 2006 - Studies are difficult to compare because of large variations in error detection methods and error definitions … This front-end error checking missed the mislabeling error in this case, probably because the requisition … Specific Errors in This Case The particular error in this case is a mislabeling error occurring outside … The Field Guide to Human Error Investigations. … error ___ Human error ___ Instrument error ___ Reagent error ___ Other analytic error Postanalytic
  4. 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
  5. 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.
  6. 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
  7. 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
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33620/psn-pdf
    September 01, 2005 - team with expertise in the area of investigation whose members were NOT directly involved with the error … While they do mention conducting "interviews with key staff involved in the error," they do not propose … My interpretation is that this includes those directly involved in the error. … can have a hard time separating themselves from the error and focusing on systems solutions. … The viewpoint of the health care provider involved in an error, however, is critical.
  9. psnet.ahrq.gov/issue/pediatric-weight-errors-and-resultant-medication-dosing-errors-emergency-department
    August 04, 2021 - Study Pediatric weight errors and resultant medication dosing errors in the emergency department. Citation Text: Hirata KM, Kang AH, Ramirez G, et al. Pediatric Weight Errors and Resultant Medication Dosing Errors in the Emergency Department. Pediatr Emerg Care. 2019;35(9):637-642. doi:1…
  10. 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
  11. 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.
  12. 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
  13. 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
  14. 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
  15. 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
  16. 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.
  17. 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
  18. 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
  19. 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
  20. psnet.ahrq.gov/web-mm/right-patient-wrong-sample
    June 01, 2004 - Studies are difficult to compare because of large variations in error detection methods and error definitions … This front-end error checking missed the mislabeling error in this case, probably because the requisition … Specific Errors in This Case The particular error in this case is a mislabeling error occurring outside … The Field Guide to Human Error Investigations. … error ___ Human error ___ Instrument error ___ Reagent error ___ Other analytic error Postanalytic

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