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Showing results for "error".
Users also searched for: medication errors

  1. 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

  2. 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

  3. 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

  4. 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

  5. Improving insulin distribution and administration safety using Lean Six Sigma methodologies. | PSNet

    psnet.ahrq.gov/issue/improving-insulin-distribution-and-administration-safety-using-lean-six-sigma-methodologies
    March 19, 2019 - 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.

  6. 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.

  7. 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

  8. 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

  9. 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

  10. 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

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49552/psn-pdf
    January 01, 2008 - Understand coping strategies, including error disclosure. … is difficult, although 2 factors related to the error itself have been proposed. … felt for the error. … The resident was devastated by the error. … Medical error: the second victim. The doctor who makes the mistake needs help too.

  12. 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/

  13. 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

  14. 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

  15. 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

  16. Dealing honestly with an honest mistake. | PSNet

    psnet.ahrq.gov/issue/dealing-honestly-honest-mistake
    March 24, 2019 - 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.

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38814/psn-pdf
    July 29, 2009 - Pediatric vaccination errors: application of the "5 rights" framework to a national error reporting … Pediatric vaccination errors: application of the "5 rights" framework to a national error reporting … https://psnet.ahrq.gov/issue/pediatric-vaccination-errors-application-5-rights-framework-national-error … - reporting-database This study analyzed more than 600 pediatric vaccination error reports from MEDMARX … https://psnet.ahrq.gov/issue/pediatric-vaccination-errors-application-5-rights-framework-national-error-reporting-database

  18. Common cause analysis. | PSNet

    psnet.ahrq.gov/issue/common-cause-analysis
    June 27, 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. … May 7, 2018 ISMP medication error report analysis.

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45834/psn-pdf
    February 22, 2017 - Implementing an error disclosure coaching model: a multicenter case study. … Implementing an error disclosure coaching model: A multicenter case study. … https://psnet.ahrq.gov/issue/implementing-error-disclosure-coaching-model-multicenter-case-study This … study described a demonstration project to enhance error disclosure. … ://psnet.ahrq.gov/primer/disclosure-errors https://psnet.ahrq.gov/issue/medical-error-second-victim

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40527/psn-pdf
    June 15, 2011 - Online medication error graphic reports: a pilot in North Carolina nursing homes. … Online medication error graphic reports: a pilot in North Carolina nursing homes. … https://psnet.ahrq.gov/issue/online-medication-error-graphic-reports-pilot-north-carolina-nursing-homes … All North Carolina nursing homes are required to report medication error data. … This study reports on a pilot effort to feed back data on error rates to individual nursing homes.
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