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461. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36028/psn-pdf
     March 28, 2011 - Computer based medication error reporting: insights and implications. … Computer based medication error reporting: insights and implications. … https://psnet.ahrq.gov/issue/computer-based-medication-error-reporting-insights-and-implications The … researchers analyzed 581 medication error reports collected from a large children's medical center … https://psnet.ahrq.gov/issue/computer-based-medication-error-reporting-insights-and-implications

462. Start using a checklist, PRONTO: recommendation for a standard review process for chemotherapy orders. | PSNet
     psnet.ahrq.gov/issue/start-using-checklist-pronto-recommendation-standard-review-process-chemotherapy-orders
     March 04, 2015 - 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.

463. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34597/psn-pdf
     March 28, 2005 - Mistaking error. March 28, 2005 Cook RI, Woods DD. Chapter in: Youngberg BJ, Hatlie, MJ, ed. … https://psnet.ahrq.gov/issue/mistaking-error This chapter discusses the "New Look" as a paradigm shift … in understanding the complexity of error and how to seek solutions to mitigate it. … The difficulty in identifying "error" is framed in the work of Rasmussen and Hollnagel. … https://psnet.ahrq.gov/issue/mistaking-error https://psnet.ahrq.gov/issue/role-error-organizing-behaviour

464. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46739/psn-pdf
     January 24, 2019 - Symptom–Disease Pair Analysis of Diagnostic Error (SPADE): a conceptual framework and methodological … Symptom-Disease Pair Analysis of Diagnostic Error (SPADE): a conceptual framework and methodological … https://psnet.ahrq.gov/issue/symptom-disease-pair-analysis-diagnostic-error-spade-conceptual-framework … This article describes a framework to address gaps in measuring diagnostic error. … https://psnet.ahrq.gov/issue/symptom-disease-pair-analysis-diagnostic-error-spade-conceptual-framework-and-methodological

465. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45225/psn-pdf
     June 15, 2016 - A case of transfusion error in a trauma patient with subsequent root cause analysis leading to institutional … A case of transfusion error in a trauma patient with subsequent root cause analysis leading to institutional … https://psnet.ahrq.gov/issue/case-transfusion-error-trauma-patient-subsequent-root-cause-analysis-leading … This case analysis discusses a wrong-patient transfusion error in a hospital's emergency room and reviews … https://psnet.ahrq.gov/issue/hospital-based-transfusion-error-tracking-2005-2010-identifying-key-errors-threatening

466. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36359/psn-pdf
     October 26, 2010 - How might acknowledging a medical error promote patient safety? … How might acknowledging a medical error promote patient safety? J Fam Pract. 2006;55(9):775-80. … https://psnet.ahrq.gov/issue/how-might-acknowledging-medical-error-promote-patient-safety The authors …  present a case of diagnostic error and use a question-and-answer format to review how to disclose and … //#error

467. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36127/psn-pdf
     September 29, 2010 - Fatality involving vinblastine overdose as a result of a complex medical error. … Fatality involving vinblastine overdose as a result of a complex medical error. … https://psnet.ahrq.gov/issue/fatality-involving-vinblastine-overdose-result-complex-medical-error The … authors investigated a fatal chemotherapy-related error and identified contributing factors that led … ://psnet.ahrq.gov//#error

468. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36704/psn-pdf
     March 28, 2011 - Stopping the error cascade: a report on ameliorators from the ASIPS collaborative. … Stopping the error cascade: a report on ameliorators from the ASIPS collaborative. … https://psnet.ahrq.gov/issue/stopping-error-cascade-report-ameliorators-asips-collaborative The investigators … qualitatively analyzed error reports from the primary care setting in which an error had been caught … https://psnet.ahrq.gov/issue/stopping-error-cascade-report-ameliorators-asips-collaborative

469. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35401/psn-pdf
     April 06, 2011 - What constitutes a prescribing error in paediatrics? … What constitutes a prescribing error in paediatrics? Qual Saf Health Care. 2005;14(5):352-7. … https://psnet.ahrq.gov/issue/what-constitutes-prescribing-error-paediatrics The authors used a Delphi … technique to gather expert opinion on what constitutes a prescribing error in pediatrics. … https://psnet.ahrq.gov/issue/what-constitutes-prescribing-error-paediatrics

470. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43272/psn-pdf
     June 18, 2014 - Physician assistants and the disclosure of medical error. … Physician assistants and the disclosure of medical error. … https://psnet.ahrq.gov/issue/physician-assistants-and-disclosure-medical-error Most existing evidence … and guidelines for error disclosure are modeled around physicians, nurses, and risk managers. … https://psnet.ahrq.gov/issue/physician-assistants-and-disclosure-medical-error https://psnet.ahrq.gov

471. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42228/psn-pdf
     October 08, 2013 - Cognitive diagnostic error in internal medicine. October 8, 2013 Van den Berge K, Mamede S. … Cognitive diagnostic error in internal medicine. … https://psnet.ahrq.gov/issue/cognitive-diagnostic-error-internal-medicine This review discusses how … confirmation bias and availability bias can contribute to diagnostic error and highlights the need for … https://psnet.ahrq.gov/issue/cognitive-diagnostic-error-internal-medicine https://psnet.ahrq.gov/issue

472. Spotlight Case [MONTH] 2003 (ppt file)
     psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.218_slideshow.ppt
     May 01, 2010 - Spotlight Case [MONTH] 2003 Spotlight Case Fatal Error in Neonate: Does ‘Just Culture’ Provide an Answer … contributions to errors in care Identify best sources of information for designing a response to an error … * Case: Fatal Error in Neonate (3) Within 4 hours of starting the lipid emulsion through the TPN … The sequence of events and underlying reasons for the error were not investigated further. … Pellegrino E.D.: Prevention of medical error: Where professional and organizational ethics meet.

473. National Patient Safety Goals. | PSNet
     psnet.ahrq.gov/issue/national-patient-safety-goals
     May 30, 2012 - 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.

474. Preventing harm from high-alert medications. | PSNet
     psnet.ahrq.gov/issue/preventing-harm-high-alert-medications
     August 14, 2017 - 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.

475. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39723/psn-pdf
     February 01, 2011 - Barriers and facilitators to chemotherapy patients' engagement in medical error prevention. … Barriers and facilitators to chemotherapy patients' engagement in medical error prevention. … https://psnet.ahrq.gov/issue/barriers-and-facilitators-chemotherapy-patients-engagement-medical-error … - prevention This study found that patients are engaged in error prevention but perceive considerable … https://psnet.ahrq.gov/issue/barriers-and-facilitators-chemotherapy-patients-engagement-medical-error-prevention

476. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37095/psn-pdf
     September 04, 2010 - Prospective error recording in surgery: an analysis of 1108 elective neurosurgical cases. … Prospective error recording in surgery: an analysis of 1108 elective neurosurgical cases. … https://psnet.ahrq.gov/issue/prospective-error-recording-surgery-analysis-1108-elective-neurosurgical … frequently, most were preventable, and 2.7% of patients experienced an adverse clinical outcome due to error … https://psnet.ahrq.gov/issue/prospective-error-recording-surgery-analysis-1108-elective-neurosurgical-cases

477. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42491/psn-pdf
     September 18, 2013 - The incidence of diagnostic error in medicine. September 18, 2013 Graber ML. … The incidence of diagnostic error in medicine. BMJ Qual Saf. 2013;22 Suppl 2:ii21-ii27. … https://psnet.ahrq.gov/issue/incidence-diagnostic-error-medicine This review examines eight research … methods used to estimate the incidence of diagnostic error and recommends tactics to improve its measurement … https://psnet.ahrq.gov/issue/incidence-diagnostic-error-medicine https://psnet.ahrq.gov/issue/overconfidence-cause-diagnostic-error-medicine

478. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36011/psn-pdf
     September 24, 2010 - Geometric probability distribution for modeling of error risk during prescription dispensing. … Geometric probability distribution for modeling of error risk during prescription dispensing. … https://psnet.ahrq.gov/issue/geometric-probability-distribution-modeling-error-risk-during-prescription … dispensing Investigators observed pharmacy staff to determine the probability of at least one dispensing error … https://psnet.ahrq.gov/issue/geometric-probability-distribution-modeling-error-risk-during-prescription-dispensing

479. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37292/psn-pdf
     May 24, 2015 - Guilty, afraid, and alone — struggling with medical error. May 24, 2015 Delbanco T, Bell SK. … Guilty, afraid, and alone--struggling with medical error. N Engl J Med. 2007;357(17):1682-3. … https://psnet.ahrq.gov/issue/guilty-afraid-and-alone-struggling-medical-error Disclosure of medical … An AHRQ WebM&M commentary, perspective, and interview also discuss multiple facets of error disclosure … https://psnet.ahrq.gov/issue/guilty-afraid-and-alone-struggling-medical-error https://psnet.ahrq.gov/

480. A crack in our best armor: "wrong patient" injections from insulin pens alarmingly frequent even with barcode scanning. | PSNet
     psnet.ahrq.gov/issue/crack-our-best-armor-wrong-patient-injections-insulin-pens-alarmingly-frequent-even-barcode
     October 22, 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. … May 29, 2019 ISMP medication error report analysis.