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  1. Medication errors related to product names. | PSNet

    psnet.ahrq.gov/issue/medication-errors-related-product-names
    January 02, 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.

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866565/psn-pdf
    August 21, 2024 - Crowdsourced feedback to improve resident physician error disclosure skills: a randomized clinical trial … Crowdsourced feedback to improve resident physician error disclosure skills: a randomized clinical trial … https://psnet.ahrq.gov/issue/crowdsourced-feedback-improve-resident-physician-error-disclosure-skills … that internal medicine and family medicine residents who received individual feedback on simulated error … https://psnet.ahrq.gov/issue/teaching-medical-error-disclosure-physicians-training-scoping-review

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867229/psn-pdf
    January 01, 2025 - Feasibility of prospective error reporting in home palliative care: a mixed methods study. … Feasibility of prospective error reporting in home palliative care: a mixed methods study. … https://psnet.ahrq.gov/issue/feasibility-prospective-error-reporting-home-palliative-care-mixed-methods … - study Error reporting and analysis is a mainstay of patient safety improvement, but voluntary reporting … in interviews approximately 1 year after an error reporting system was implemented.

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33560/psn-pdf
    June 15, 2024 - Background Many patients harmed by a medical error never learn of the error. … These include: Disclosure of all harmful errors An explanation as to why the error occurred How the … Increasing the amount and quality of error disclosure will require addressing physician discomfort with … This may also require changes in how organizations approach error disclosure. … disclosure of an error may be admissible in a malpractice lawsuit.

  5. PSNet Curated Library (pdf file)

    psnet.ahrq.gov/print/pdf/node/865864
    January 01, 2024 - PSNet Curated Library AHRQ: Agency for Healthcare Research and Quality Diagnostic Error Curated … More than 5,300 closed claims with at least one diagnostic error were analyzed. … The patient is in: patient involvement strategies for diagnostic error mitigation. … More than 5,300 closed claims with at least one diagnostic error were analyzed. … Patients' perspectives of diagnostic error: a qualitative study.

  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838926/psn-pdf
    October 26, 2022 - Position Statement on Criminalization of Medical Error and Call for Action to Prevent Patient Harm from … Error. … - patient-harm-error Criminalizing human error can deter the transparency necessary to learn from incidents … https://psnet.ahrq.gov/issue/position-statement-criminalization-medical-error-and-call-action-prevent-patient-harm-error … https://psnet.ahrq.gov/issue/position-statement-criminalization-medical-error-and-call-action-prevent-patient-harm-error

  7. 2024 Network of Patient Safety Databases Chartbook: Medication and Other Substance Events. | PSNet

    psnet.ahrq.gov/issue/2024-network-patient-safety-databases-chartbook-medication-and-other-substance-events
    September 11, 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.

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/836754/psn-pdf
    March 16, 2022 - State of science: evolving perspectives on ‘human error’. … State of science: evolving perspectives on ‘human error’. … https://psnet.ahrq.gov/issue/state-science-evolving-perspectives-human-error Human error can affect … prevent, and mitigate human error, and the role of ergonomics and human factors in reducing error. … https://psnet.ahrq.gov/issue/operating-sharp-end-complexity-human-error

  9. Wrong drug and wrong dose dispensing errors identified in pharmacist professional liability claims. | PSNet

    psnet.ahrq.gov/issue/wrong-drug-and-wrong-dose-dispensing-errors-identified-pharmacist-professional-liability
    August 31, 2016 - 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.

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/860389/psn-pdf
    January 10, 2024 - Error codes at autopsy to study potential biases in diagnostic error. … Error codes at autopsy to study potential biases in diagnostic error. … https://psnet.ahrq.gov/issue/error-codes-autopsy-study-potential-biases-diagnostic-error Autopsies are … https://psnet.ahrq.gov/issue/error-codes-autopsy-study-potential-biases-diagnostic-error https://psnet.ahrq.gov

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866690/psn-pdf
    September 11, 2024 - The effectiveness of checklists and error reporting systems in enhancing patient safety and reducing … The effectiveness of checklists and error reporting systems in enhancing patient safety and reducing … https://psnet.ahrq.gov/issue/effectiveness-checklists-and-error-reporting-systems-enhancing-patient-safety … - and-reducing Checklists and error reporting systems are designed to improve patient safety. … psnet.ahrq.gov/issue/effects-leadership-self-worth-inclusion-trust-and-psychological-safety-medical-error

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867639/psn-pdf
    February 26, 2025 - Framing diagnostic error: an epidemiological perspective. … Framing diagnostic error: an epidemiological perspective. … https://psnet.ahrq.gov/issue/framing-diagnostic-error-epidemiological-perspective Diagnostic error continues … This narrative review presents ways to improve epidemiological research into diagnostic error. … Definitions of "diagnostic error" vary greatly between studies.

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47586/psn-pdf
    March 20, 2019 - Wrong-patient blood transfusion error: leveraging technology to overcome human error in intraoperative … Wrong-Patient Blood Transfusion Error: Leveraging Technology to Overcome Human Error in Intraoperative … https://psnet.ahrq.gov/issue/wrong-patient-blood-transfusion-error-leveraging-technology-overcome- human-error … https://psnet.ahrq.gov/issue/wrong-patient-blood-transfusion-error-leveraging-technology-overcome-human-error … https://psnet.ahrq.gov/issue/wrong-patient-blood-transfusion-error-leveraging-technology-overcome-human-error

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45346/psn-pdf
    November 18, 2016 - How do simulated error experiences impact attitudes related to error prevention? … How Do Simulated Error Experiences Impact Attitudes Related to Error Prevention? … https://psnet.ahrq.gov/issue/how-do-simulated-error-experiences-impact-attitudes-related-error-prevention … One group participated in simulated error experiences while the other watched movies about error; both … https://psnet.ahrq.gov/issue/how-do-simulated-error-experiences-impact-attitudes-related-error-prevention

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866244/psn-pdf
    July 10, 2024 - Optimizing the use of dose error reduction software on intravenous infusion pumps. … Optimizing the use of dose error reduction software on intravenous infusion pumps. … https://psnet.ahrq.gov/issue/optimizing-use-dose-error-reduction-software-intravenous-infusion-pumps … Smart pumps with dose error reduction software (DERS) can reduce adverse drug events, but alert fatigue … https://psnet.ahrq.gov/issue/optimizing-use-dose-error-reduction-software-intravenous-infusion-pumps

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865704/psn-pdf
    May 01, 2024 - Supporting error management and safety climate in ambulatory care practices: the CIRSforte study. … Supporting error management and safety climate in ambulatory care practices: the CIRSforte study. … https://psnet.ahrq.gov/issue/supporting-error-management-and-safety-climate-ambulatory-care-practices … This study evaluated an error management and safety climate intervention implemented across 184 ambulatory … The intervention included email newsletters on error management, e-learning modules to improve team

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40070/psn-pdf
    December 08, 2010 - Epidural pump programming error leading to inadvertent 10-fold dosing error during epidural labor analgesia … Epidural Pump Programming Error Leading to Inadvertent 10- Fold Dosing Error During Epidural Labor Analgesia … https://psnet.ahrq.gov/issue/epidural-pump-programming-error-leading-inadvertent-10-fold-dosing-error … https://psnet.ahrq.gov/issue/epidural-pump-programming-error-leading-inadvertent-10-fold-dosing-error-during-epidural … https://psnet.ahrq.gov/issue/epidural-pump-programming-error-leading-inadvertent-10-fold-dosing-error-during-epidural

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50892/psn-pdf
    February 12, 2020 - Association of open communication and the emotional and behavioural impact of medical error on patients … Association of open communication and the emotional and behavioural impact of medical error on patients … impact, 57% reported avoiding the doctor(s) or facility(s) involved in the error, and two-thirds of … respondents reported a loss of trust after the medical error. … reduce persistent emotional impacts and avoidance of doctors/facilities involved in the error.

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/61062/psn-pdf
    January 01, 2022 - Vignettes can assess error awareness, assessment of harm, disclosure, and reporting practices. … Vignettes can assess error awareness, assessment of harm, disclosure, and reporting practices. … This study used clinical vignettes describing a medication error or near miss to explore error awareness … Perioperative medication error awareness and assessment of potential harm were variable, and the likelihood … Education programs utilizing vignettes should be utilized to raise awareness about error reporting and

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60887/psn-pdf
    September 09, 2020 - Human-based errors involving smart infusion pumps: a catalog of error types and prevention strategies … Human-based errors involving smart infusion pumps: a catalog of error types and prevention strategies … https://psnet.ahrq.gov/issue/human-based-errors-involving-smart-infusion-pumps-catalog-error-types-and … Error categories included (1) undocumented errors, (2) drug library  errors, (3) programming errors, … A range of prevention strategies were identified and mapped to the error types.
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