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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
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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.
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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
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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
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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.
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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
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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
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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.
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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…
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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
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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.
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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
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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
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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
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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
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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.
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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
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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
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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
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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