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9881. 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

9882. 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

9883. 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.

9884. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35700/psn-pdf
      February 15, 2010 - Point-of-care testing error: sources and amplifiers, taxonomy, prevention strategies, and detection … Point-of-care testing error: sources and amplifiers, taxonomy, prevention strategies, and detection … https://psnet.ahrq.gov/issue/point-care-testing-error-sources-and-amplifiers-taxonomy-prevention- strategies-and-detection … They provide several strategies for error reduction. … https://psnet.ahrq.gov/issue/point-care-testing-error-sources-and-amplifiers-taxonomy-prevention-strategies-and-detection

9885. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44986/psn-pdf
      April 20, 2016 - Nurses' role in medical error recovery: an integrative review. … Nurses' role in medical error recovery: an integrative review. … https://psnet.ahrq.gov/issue/nurses-role-medical-error-recovery-integrative-review This review examined … According to some studies, nurses may recover as many as one error each shift. … A strong safety culture was an important organizational enabler of effective error recovery.

9886. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39595/psn-pdf
      June 15, 2011 - Application of human error theory in case analysis of wrong procedures. June 15, 2011 Duthie EA. … Application of Human Error Theory in Case Analysis of Wrong Procedures. … https://psnet.ahrq.gov/issue/application-human-error-theory-case-analysis-wrong-procedures This study … examines five wrong-procedure cases by applying James Reason’s human error theory, and describes the … /issue/human-error https://psnet.ahrq.gov/primer/systems-approach

9887. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/35419/psn-pdf
      February 15, 2010 - College of American Pathologists Special Topic Symposium on Error in Pathology and Laboratory Medicine—Practical … https://psnet.ahrq.gov/issue/college-american-pathologists-special-topic-symposium-error-pathology-and … laboratory-medicine This issue section includes presentations from the September 2004 symposium on error … Topics covered include insurance issues, pathology databases, and general pathology and lab error reduction … https://psnet.ahrq.gov/issue/college-american-pathologists-special-topic-symposium-error-pathology-and-laboratory-medicine

9888. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40083/psn-pdf
      December 15, 2010 - Nighttime and weekend medication error rates in an inpatient pediatric population. … Nighttime and weekend medication error rates in an inpatient pediatric population. … https://psnet.ahrq.gov/issue/nighttime-and-weekend-medication-error-rates-inpatient-pediatric-population … This study found an increase in medication error rates during evening, nighttime, and weekend shifts … Medication administration and dispensing were the most common error types noted.

9889. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36782/psn-pdf
      August 26, 2011 - A review of medical error reporting system design considerations and a proposed cross-level systems … A review of medical error reporting system design considerations and a proposed cross-level systems … https://psnet.ahrq.gov/issue/review-medical-error-reporting-system-design-considerations-and-proposed … - cross-level-systems The authors review the literature on medical error reporting systems and propose … https://psnet.ahrq.gov/issue/review-medical-error-reporting-system-design-considerations-and-proposed-cross-level-systems

9890. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40843/psn-pdf
      October 12, 2011 - Error rates in breast imaging reports: comparison of automatic speech recognition and dictation transcription … Error rates in breast imaging reports: comparison of automatic speech recognition and dictation transcription … https://psnet.ahrq.gov/issue/error-rates-breast-imaging-reports-comparison-automatic-speech-recognition … - and-dictation Dictated radiology reports were far more likely to contain a major error if transcribed … https://psnet.ahrq.gov/issue/error-rates-breast-imaging-reports-comparison-automatic-speech-recognition-and-dictation

9891. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/33628/psn-pdf
      February 01, 2006 - for sure that this error caused the harm." … If she looked at me in shock and said, "An error?" … I would say, "Yes, there was an error in the course of her care. … And we believe this medication error caused the problems that she had. … JB: Error disclosure is obviously the ethical thing to do.

9892. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45338/psn-pdf
      July 20, 2016 - Understanding models of error and how they apply in clinical practice. … https://psnet.ahrq.gov/issue/understanding-models-error-and-how-they-apply-clinical-practice Human error … This commentary summarizes core concepts of human error and discusses how they can be applied to promote … https://psnet.ahrq.gov/issue/understanding-models-error-and-how-they-apply-clinical-practice https:// … psnet.ahrq.gov/issue/human-error-models-and-management https://psnet.ahrq.gov/perspective/count-and-be-counted-preparing-future-pharmacists-promote-culture-safety

9893. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44040/psn-pdf
      August 02, 2015 - why-physicians-err-diagnosis This previously published commentary provides a historical glimpse into diagnostic error … The piece discusses the value of autopsy in uncovering incorrect diagnoses, suggests that physician error … be classified as either social or clinical in nature, and explores factors that contribute to error … https://psnet.ahrq.gov/issue/cognitive-interventions-reduce-diagnostic-error-narrative-review https: … //psnet.ahrq.gov/issue/autopsy-advocates https://psnet.ahrq.gov/issue/human-error

9894. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40788/psn-pdf
      September 21, 2011 - Not overstepping professional boundaries: the challenging role of nurses in simulated error disclosures … Not overstepping professional boundaries: the challenging role of nurses in simulated error disclosures … //psnet.ahrq.gov/issue/not-overstepping-professional-boundaries-challenging-role-nurses-simulated- error-disclosures … This study revealed that nurses perceived their role in team-based error disclosure as secondary to … https://psnet.ahrq.gov/issue/not-overstepping-professional-boundaries-challenging-role-nurses-simulated-error-disclosures

9895. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40556/psn-pdf
      June 29, 2011 - A review of medical error taxonomies: a human factors perspective. … A review of medical error taxonomies: A human factors perspective. … https://psnet.ahrq.gov/issue/review-medical-error-taxonomies-human-factors-perspective This review compared … 26 medical error taxonomies using a human factors perspective and demonstrated that each taxonomy provides … highlight the importance of taxonomies that use knowledge of cognitive mechanisms and theoretical error

9896. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46685/psn-pdf
      January 17, 2018 - Insulin dosing error in a patient with severe hyperkalemia. … Insulin Dosing Error in a Patient With Severe Hyperkalemia. … https://psnet.ahrq.gov/issue/insulin-dosing-error-patient-severe-hyperkalemia This case report describes … an insulin dosing error during hospitalization. … https://psnet.ahrq.gov/issue/insulin-dosing-error-patient-severe-hyperkalemia https://psnet.ahrq.gov/

9897. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44093/psn-pdf
      April 29, 2015 - South Carolina medication error bill is dangerously off target. … https://psnet.ahrq.gov/issue/south-carolina-medication-error-bill-dangerously-target This newsletter … article reports on issues related to a legislation, drafted in response to a tenfold dosing error, … One particular concern highlighted is that the bill does not recognize the role of human error and systems … https://psnet.ahrq.gov/issue/south-carolina-medication-error-bill-dangerously-target https://psnet.ahrq.gov

9898. 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.

9899. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38433/psn-pdf
      February 25, 2009 - The impact of trained assistance on error rates in anaesthesia: a simulation-based randomised controlled … The impact of trained assistance on error rates in anaesthesia: a simulation-based randomised controlled … https://psnet.ahrq.gov/issue/impact-trained-assistance-error-rates-anaesthesia-simulation-based- randomised-controlled … This study used simulation-based training of anesthetists to demonstrate a reduction in error rates … https://psnet.ahrq.gov/issue/impact-trained-assistance-error-rates-anaesthesia-simulation-based-randomised-controlled

9900. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/36198/psn-pdf
      March 28, 2011 - Using human error theory to explore the supply of non- prescription medicines from community pharmacies … Using human error theory to explore the supply of non- prescription medicines from community pharmacies … https://psnet.ahrq.gov/issue/using-human-error-theory-explore-supply-non-prescription-medicines- community-pharmacies … The authors applied human error theory to study consultations for over-the-counter medications in  … https://psnet.ahrq.gov/issue/using-human-error-theory-explore-supply-non-prescription-medicines-community-pharmacies