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221. Human Error: Cause, Prediction and Reduction. | PSNet
     psnet.ahrq.gov/issue/human-error-cause-prediction-and-reduction
     July 13, 2016 - Book/Report Classic Human Error: Cause, Prediction and … Citation Text: Human Error: Cause, Prediction and Reduction. Senders JW, Morey NP. … Linkedin Copy URL Cite Citation Citation Text: Human Error … Copy Citation Related Resources From the Same Author(s) Human Error in Medicine … July 13, 2016 Operating at the sharp end: the complexity of human error.

222. Duty to Disclose Someone Else's Error? | PSNet
     psnet.ahrq.gov/web-mm/duty-disclose-someone-elses-error
     June 01, 2004 - Duty to Disclose Someone Else's Error?. PSNet [internet]. … error, fears of retaliation can ensue. … If they determined that a clear error occurred, providers should have found a way to disclose the error … If other providers have committed an error, optimal strategies involve full collaboration in error investigation … and joint disclosure if an error did occur.

223. Error rate greatest in hospital radiology. | PSNet
     psnet.ahrq.gov/issue/error-rate-greatest-hospital-radiology
     December 24, 2008 - Newspaper/Magazine Article Error rate greatest in hospital radiology. … Citation Text: Error rate greatest in hospital radiology. … Linkedin Copy URL Cite Citation Citation Text: Error

224. Next Steps and a Call to Action | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions6.html
     June 01, 2023 - of care represent a vulnerable moment for patients and families with high potential for diagnostic error … Each unique context carries its own risks for diagnostic error. … Table 1 highlights and summarizes specific strategies that can help mitigate diagnostic error at each … Care transitions, sources of error, and potential mitigating strategies Care Transition … to scale up and nationally implement effective tools to mitigate diagnostic error.

225. Inpatient-to-Outpatient Transitions | Agency for Healthcare Research and Quality
     www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions5.html
     June 01, 2023 - patients transition from the inpatient to outpatient setting, is perhaps the setting where diagnostic error … In one study, 49 percent of patients experienced at least one medical error after discharge, related … review and adjudication process to categorize diagnostic error. … A systematic review of cognitive interventions to reduce diagnostic error across healthcare settings … However, most interventions were not tested directly for error reduction in clinical practice.

226. Error detection and recovery in dialysis nursing. | PSNet
     psnet.ahrq.gov/issue/error-detection-and-recovery-dialysis-nursing
     November 16, 2022 - Study Error detection and recovery in dialysis nursing. … Error detection and recovery in dialysis nursing. … Error detection and recovery in dialysis nursing. … November 16, 2022 Families as partners in hospital error and adverse event surveillance … January 7, 2015 Comprehensive analysis of a medication dosing error related to CPOE.

227. Diagnostic Error Measures: For Quality Improvement & Patient Safety Research (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/news/events/ahrq-research-summit/adelman-summit2016.pdf
     January 01, 2016 - Diagnostic Error Measures: For Quality Improvement & Patient Safety Research Diagnostic Error Measures … Diagnostic Error Measures Types of Patient Safety & Quality Measures xxVoluntary Reporting Chart … trigger report • PPV > 70% • Requires programming • Fully automated IOM Definition: Diagnostic Error … JAMA. 2001;285:2114-2120 Wrong-Patient Error Measures Retract-and-Reorder Tool Applied to Complete … Diagnostic Error Measures:�For Quality Improvement & �Patient Safety Research Slide Number 2 Slide

228. AHRQ WebM&M—Online Medical Error Reporting and Analysis (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Wachter.pdf
     March 11, 2005 - AHRQ WebM&M—Online Medical Error Reporting and Analysis 211 AHRQ WebM&M—Online Medical Error Reporting … Online Error Reporting and Analysis 215 Cases.” … Online Error Reporting and Analysis 217 Table 2. … Online Error Reporting and Analysis 221 6. Orlander JD, Fincke BG. … Adverse event/error types among published cases* Figure 1.

229. Bar code technology and medication administration error. | PSNet
     psnet.ahrq.gov/issue/bar-code-technology-and-medication-administration-error
     June 07, 2023 - Review Bar code technology and medication administration error. … Bar Code Technology and Medication Administration Error. … Bar Code Technology and Medication Administration Error.

230. Pathologists' perspectives on disclosing harmful pathology error. | PSNet
     psnet.ahrq.gov/issue/pathologists-perspectives-disclosing-harmful-pathology-error
     January 22, 2020 - Study Pathologists' perspectives on disclosing harmful pathology error. … Pathologists' Perspectives on Disclosing Harmful Pathology Error. … Pathologists' Perspectives on Disclosing Harmful Pathology Error. … April 21, 2011 Video-based communication assessment of physician error disclosure skills … February 17, 2017 Error disclosure in pathology and laboratory medicine: a review of

231. How Do Providers Recover From Errors? | PSNet
     psnet.ahrq.gov/web-mm/how-do-providers-recover-errors
     May 22, 2024 - 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.

232. The AAFP Patient Safety Reporting System: Development and Legal Issues Pertinent to Medical Error Tracking and Analysis (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Phillips.pdf
     January 01, 2004 - The main outcome measures were error category, error rate, and error consequence. … Distribution of error types from three AAFP error-report studies Error types AAFP 1st study (n = … 330) % error reports International (n = 429) % error reports AAFP 2nd study* (n = 838) % error … an investigation error code and a communication error code). … Distribution of error types from three AAFP error-report studies Table 2.

233. Fatal error sparks debate over punitive measures.  | PSNet
     psnet.ahrq.gov/issue/fatal-error-sparks-debate-over-punitive-measures
     May 20, 2020 - Newspaper/Magazine Article Fatal error sparks debate over punitive measures.  … Citation Text: Fatal error sparks debate over punitive measures.  Fernandez J. Drug Topics. … Linkedin Copy URL Cite Citation Citation Text: Fatal error … March 18, 2010 Former pharmacist indicted for manslaughter after med error.

234. Poor physician-patient communication and medical error. | PSNet
     psnet.ahrq.gov/issue/poor-physician-patient-communication-and-medical-error
     August 23, 2023 - Commentary Poor physician-patient communication and medical error. … Citation Text: Poor physician-patient communication and medical error. … Cite Citation Citation Text: Poor physician-patient communication and medical error … October 14, 2020 The practice of medicine: understanding diagnostic error.

235. Microsoft PowerPoint - Spotlight Case_Anesthesia Error During Cesarean_06.22.2023 - Final.pptx (pdf file)
     psnet.ahrq.gov/sites/default/files/2023-06/hurried_huddle_0.pdf
     January 01, 2023 - Microsoft PowerPoint - Spotlight Case_Anesthesia Error During Cesarean_06.22.2023 - Final.pptx Spotlight … 18 Contributing Factors (2) There are multiple factors that likely contributed to this medical error … Approach to Improving Patient Safety (1) Multiple practices can help reduce the risk of a similar medical error

236. Defining Diagnostic Error: A Scoping Review to Assess the Impact of the National Academies’ Report Improving Diagnosis in Health Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/topics/defining-diagnostic-error-a-scoping-review.pdf
     April 27, 2022 - Three studies operationalized error using existing definitions only. … in published peer-reviewed diagnostic error research?” … error work is to improve the care of patients.” … Clinician survey on diagnostic error Clinician survey on diagnostic error Accuracy Timeliness … Patients’ perspectives of diagnostic error: a qualitative study.

237. Medication errors and error chains involving high-alert medications in a paediatric hospital setting: a qualitative analysis of self-reported medication safety incidents. | PSNet
     psnet.ahrq.gov/issue/medication-errors-and-error-chains-involving-high-alert-medications-paediatric-hospital
     March 27, 2024 - 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.

238. Standardizing Medication Error Event Reporting in the U.S. Department of Defense (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Nosek.pdf
     March 01, 2004 - in the MEDMARX system, including medication use process node, type of error, cause of error, and contributing … ,” “error result on patient care,” and “medical devices involved in the error.” … Council for Medication Error Reporting and Prevention error categories. … by “omission error.” … taken related to the error.

239. A Visual Computer Interface Concept for Making Error Reporting Useful at the Point of Care (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Singh_69.pdf
     April 04, 2008 - We present a concept for a visual error reporting interface. … Error Taxonomies Error Taxonomies A number of error taxonomies have been and are being developed to … organize and classify error reports. … In this case, the error is that the primary doctor (who is reporting this error) refilled the wrong … route Wrong # of doses Wrong #of refills StorySeverity Click on this error Click where the error

240. Does Medical Error Disclosure Violate the Medical Malpractice Insurance Cooperation Clause? (pdf file)
     www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol3/Banja.pdf
     January 01, 2004 - Does Medical Error Disclosure Violate the Medical Malpractice Insurance Cooperation Clause? … 371 Does Medical Error Disclosure Violate the Medical Malpractice Insurance Cooperation Clause? … The frank admission of a harm-causing error—e.g., “Mrs. … truthful disclosure of harm-causing error. … Error Disclosure and Malpractice Insurance 377 Should Mr.