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pso.ahrq.gov/pso/emergency-medical-error-reduction-group-0
March 08, 2022 - Return to Delisted PSOs Search
Emergency Medical Error
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psnet.ahrq.gov/issue/first-know-thyself-cognition-and-error-medicine
March 09, 2022 - Review
"First, know thyself": cognition and error in medicine. … "First, know thyself": cognition and error in medicine. … Cognition has been recognized as a human factor that can contribute to medical error. … This review explores cognitive psychology as a method to understand diagnostic error , particularly … "First, know thyself": cognition and error in medicine.
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psnet.ahrq.gov/issue/state-science-evolving-perspectives-human-error
February 22, 2023 - Commentary
State of science: evolving perspectives on ‘human error’. … State of science: evolving perspectives on ‘human error’. … Human error can affect the safety of care delivery. … , prevent, and mitigate human error, and the role of ergonomics and human factors in reducing error. … State of science: evolving perspectives on ‘human error’.
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psnet.ahrq.gov/issue/taking-blame-appropriate-responses-medical-error
September 23, 2020 - Commentary
Taking the blame: appropriate responses to medical error. … Taking the blame: appropriate responses to medical error. … Balancing between explicit calls for accountability for error and constructive discussion of mistakes … discusses blame in the context of medical errors and suggests that healthy acceptance of responsibility for error … Taking the blame: appropriate responses to medical error.
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psnet.ahrq.gov/issue/regulating-compensation-injuries-associated-medical-error
February 15, 2023 - Commentary
Regulating compensation for injuries associated with medical error. … Citation Text:
Regulating compensation for injuries associated with medical error. Corbett A. … The author discusses developing "no-fault" systems of compensation for victims of medical error in Australia … Citation
Citation Text:
Regulating compensation for injuries associated with medical error … June 25, 2010
Medical error reduction and tort reform through private contractually-based
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psnet.ahrq.gov/issue/systematic-error-and-cognitive-bias-obstetric-ultrasound
December 13, 2023 - Commentary
Systematic error and cognitive bias in obstetric ultrasound. … Systematic error and cognitive bias in obstetric ultrasound. … The authors review systemic factors that facilitate this type of error and suggest avenues for improvement … Systematic error and cognitive bias in obstetric ultrasound. … September 4, 2019
Error and Uncertainty in Diagnostic Radiology.
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digital.ahrq.gov/health-it-tools-and-resources/ahrq-funded-project-resources-archives/primary-care-visual-error
January 01, 2023 - Primary Care Visual Error Reporting Tool
Description
The Primary Care Visual … Medication Error Reporting Tool is a tool using pictures/diagrams to be used in the reporting of errors … Improving Medication Safety with Clinician Use of Health IT
PDF
Primary Care Visual Error
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psnet.ahrq.gov/issue/chemotherapy-error-practical-approaches-increasing-patient-safety
August 04, 2021 - Commentary
Chemotherapy error: practical approaches to increasing patient safety. … Chemotherapy Error. J Patient Saf. 2008;1(4). doi:10.1097/01.jps.0000215340.80935.d0. … Chemotherapy Error. J Patient Saf. 2008;1(4). doi:10.1097/01.jps.0000215340.80935.d0. … June 16, 2019
ISMP medication error report analysis. … June 16, 2019
ISMP medication error report analysis.
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psnet.ahrq.gov/primer/coronavirus-disease-2019-covid-19-and-diagnostic-error
July 30, 2020 - Coronavirus Disease 2019 (COVID-19) and Diagnostic Error
Citation Text:
Desai AN, Romano … Coronavirus Disease 2019 (COVID-19) and Diagnostic Error. PSNet [internet]. … Coronavirus Disease 2019 (COVID-19) and Diagnostic Error. PSNet [internet]. … Reducing the risk of diagnostic error in the COVID-19 era. J Hosp Med . 2020;15(6):363-366. … Coronavirus Disease 2019 (COVID-19) and Diagnostic Error. PSNet [internet].
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psnet.ahrq.gov/issue/error-and-cognitive-bias-diagnostic-radiology
August 07, 2013 - Commentary
Error and cognitive bias in diagnostic radiology. … Error and cognitive bias in diagnostic radiology. … of the common cognitive biases encountered in diagnostic radiology that can contribute to diagnostic error … Error and cognitive bias in diagnostic radiology. … 11, 2021
Cognitive bias impact on management of postoperative complications, medical error
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psnet.ahrq.gov/issue/when-surgical-colleague-makes-error
December 21, 2014 - Commentary
When a surgical colleague makes an error. … When a Surgical Colleague Makes an Error. … recognizing and disclosing errors to patients in the past few decades, but speaking up about a peer's error … When a Surgical Colleague Makes an Error. … September 20, 2011
Families as partners in hospital error and adverse event surveillance
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psnet.ahrq.gov/issue/error-training-missing-link-surgical-education
December 21, 2014 - Review
Error training: missing link in surgical education. … Error training: missing link in surgical education. … Reviewing the evidence for integrating medical error education into existing curricula, this commentary … Error training: missing link in surgical education. … ' error recovery strategies.
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psnet.ahrq.gov/issue/medical-device-use-error-root-cause-analysis
January 10, 2018 - Book/Report
Medical Device Use Error: Root Cause Analysis. … Citation Text:
Medical Device Use Error: Root Cause Analysis. Wiklund M, Dwyer A, Davis E. … The book includes examples of RCAs to illustrate how the method can uncover flaws that contribute to error … URL
Cite
Citation
Citation Text:
Medical Device Use Error … April 12, 2017
Behind Human Error, Second Edition.
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psnet.ahrq.gov/issue/economic-impact-medication-error-systematic-review
November 04, 2020 - Review
Economic impact of medication error: a systematic review. … Economic impact of medication error: a systematic review. … This systematic review of the costs associated with medication errors found that estimated costs per error … Economic impact of medication error: a systematic review. … June 16, 2021
Human-based errors involving smart infusion pumps: a catalog of error types
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psnet.ahrq.gov/issue/incidence-nature-and-impact-error-surgery
December 16, 2020 - Study
Incidence, nature and impact of error in surgery. … Incidence, nature and impact of error in surgery. … This study noted a 6% error rate for patients admitted to a surgical ward with nearly 70% having little … Incidence, nature and impact of error in surgery. … December 8, 2021
Trial and error: learning from malpractice claims in childhood surgery
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psnet.ahrq.gov/issue/higher-ground-ethical-reasoning-and-its-relationship-error-disclosure
July 08, 2020 - Study
On higher ground: ethical reasoning and its relationship with error disclosure … On higher ground: ethical reasoning and its relationship with error disclosure. … This study investigated the role of physicians' personal morality in attitudes toward error disclosure … , apologize for the error, and acknowledge personal responsibility. … On higher ground: ethical reasoning and its relationship with error disclosure.
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psnet.ahrq.gov/issue/patient-error-preliminary-taxonomy
June 02, 2010 - Study
Patient error: a preliminary taxonomy. … Patient error: a preliminary taxonomy. Ann Fam Med. 2009;7(3):223-31. doi:10.1370/afm.941. … Patient error: a preliminary taxonomy. Ann Fam Med. 2009;7(3):223-31. doi:10.1370/afm.941. … November 3, 2021
WebM&M Cases
Workaround Error
February
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www.ahrq.gov/sites/default/files/2025-04/graber-report.pdf
January 01, 2025 - and
a practical group of sessions (Day 2 – Reducing Diagnostic Error). … decision-support tools and
organizational approaches to error reduction. … AHRQ’s interest in patient safety, medical
error, and diagnostic error in particular was emphasized … You had the clinicians speaking who are measuring, defining diagnostic error. … Consider error rates of ideal observers and systems.
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psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-18
December 30, 2014 - Commentary
ISMP medication error report analysis. … Citation Text:
ISMP medication error report analysis. Cohen MR; Smetzer JL. … June 16, 2019
ISMP medication error report analysis. … June 16, 2019
ISMP medication error report analysis. … June 9, 2010
ISMP medication error report analysis.
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psnet.ahrq.gov/issue/nature-human-error-implications-surgical-practice
March 24, 2021 - Review
Nature of human error: implications for surgical practice. … Nature of human error: implications for surgical practice. Ann Surg. 2006;244(5):642-8. … safe surgical care and determine what research is needed to deepen the understanding of how human error … Nature of human error: implications for surgical practice. Ann Surg. 2006;244(5):642-8. … An overview of error causation and prevention.