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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837960/psn-pdf
    August 31, 2022 - Interventions to reduce the incidence of medical error and its financial burden in health care systems … Interventions to reduce the incidence of medical error and its financial burden in health care systems … https://psnet.ahrq.gov/issue/interventions-reduce-incidence-medical-error-and-its-financial-burden-health … This review identified eight categories of hospital-acquired conditions (i.e., overall medical error … , medication error, diagnostic error, patient falls, healthcare-associated infections, transfusion and

  2. The rate and costs attributable to intravenous patient-controlled analgesia errors. | PSNet

    psnet.ahrq.gov/issue/rate-and-costs-attributable-intravenous-patient-controlled-analgesia-errors
    April 29, 2010 - April 29, 2010 Hierarchy and medical error: speaking up when witnessing an error. … 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.

  3. Murphy Diagram | Digital Healthcare Research

    digital.ahrq.gov/health-it-tools-and-resources/evaluation-resources/workflow-assessment-health-it-toolkit/all-workflow-tools/murphy-diagram
    January 01, 2023 - DEFINE ERROR EVENTS. Begin by defining the first error as clearly as possible. 4. … CLASSIFY ERROR ACTIVITY INTO DECISIONMAKING CATEGORY. … DETERMINE ERROR CONSEQUENCE AND CAUSES. … of the error are. 6. … Advantages Allows multiple potential causes for an error to be identified.

  4. Feeling No Pain | PSNet

    psnet.ahrq.gov/web-mm/feeling-no-pain
    August 30, 2023 - Human error in medicine: a frontier for change. In: Bogner, MS, ed. Human error in medicine. … Stretching the search for the “why” of error: the systems approach. … Identifying error provoking factors: the systems approach. … The systems approach analysis of error. … Error reduction as a systems problem. In: Bogner MS, ed. Human error in medicine.

  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36972/psn-pdf
    June 16, 2019 - ISMP medication error report analysis. June 16, 2019 Cohen MR. … ISMP medication error report analysis. Hosp Pharm. 2010;42(6):498-499. doi:10.1310/hpj4206- 498. … error reports includes an error averted because the pharmacist checked the patient's prior prescription … data and a dosing error due to consumer confusion about dose measurement. … https://psnet.ahrq.gov/issue/ismp-medication-error-report-analysis-14

  6. Medication errors and drug-dispensing systems in a hospital pharmacy. | PSNet

    psnet.ahrq.gov/issue/medication-errors-and-drug-dispensing-systems-hospital-pharmacy
    November 18, 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.

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60198/psn-pdf
    April 08, 2020 - Hierarchy and medical error: speaking up when witnessing an error. … Hierarchy and medical error: speaking up when witnessing an error. … https://psnet.ahrq.gov/issue/hierarchy-and-medical-error-speaking-when-witnessing-error A key tenet … https://psnet.ahrq.gov/issue/hierarchy-and-medical-error-speaking-when-witnessing-error https://psnet.ahrq.gov

  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/48076/psn-pdf
    July 24, 2019 - Simulation-based event analysis improves error discovery and generates improved strategies for error … Simulation-based event analysis improves error discovery and generates improved strategies for error … https://psnet.ahrq.gov/issue/simulation-based-event-analysis-improves-error-discovery-and-generates- … simulation format and compared to traditional RCA, simulation participants identified novel sources of error … https://psnet.ahrq.gov/issue/simulation-based-event-analysis-improves-error-discovery-and-generates-improved-strategies

  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/845636/psn-pdf
    March 08, 2023 - The effects of leadership for self-worth, inclusion, trust, and psychological safety on medical error … The effects of leadership for self-worth, inclusion, trust, and psychological safety on medical error … psnet.ahrq.gov/issue/effects-leadership-self-worth-inclusion-trust-and-psychological-safety-medical- error … This study reports on how trust and psychological safety interact to increase error reporting. … Results indicate that trust in leaders encouraged error reporting and psychological safety encouraged

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60649/psn-pdf
    July 01, 2020 - The differences between human error, at-risk behavior, and reckless behavior are key to a just culture … July 1, 2020 The differences between human error, at-risk behavior, and reckless behavior are key to … https://psnet.ahrq.gov/issue/differences-between-human-error-risk-behavior-and-reckless-behavior-are- … This article compares human error, at-risk behavior, and reckless behavior to suggest systems design … https://psnet.ahrq.gov/issue/human-error-models-and-management

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60304/psn-pdf
    January 01, 2021 - Patients' perspectives of diagnostic error: a qualitative study. … Patients' perspectives of diagnostic error: a qualitative study. … https://psnet.ahrq.gov/issue/patients-perspectives-diagnostic-error-qualitative-study Using the IOM … Qualitative analysis revealed five main themes underlying the causes of diagnostic error: problems with … Suggested strategies to reduce diagnostic error included improvements to clinical management, increase

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837800/psn-pdf
    August 10, 2022 - Preferences and perceptions of medical error disclosure among marginalized populations: a narrative … Preferences and perceptions of medical error disclosure among marginalized populations: a narrative … https://psnet.ahrq.gov/issue/preferences-and-perceptions-medical-error-disclosure-among-marginalized- … populations-narrative Patients and families prefer to be told if they experience a medical error. … This systematic review identified 6 studies focused on error disclosure in one of three marginalized

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838075/psn-pdf
    September 14, 2022 - Crisis recovery in surgery: error management and problem solving in safety-critical situations. … Crisis recovery in surgery: error management and problem solving in safety-critical situations. … https://psnet.ahrq.gov/issue/crisis-recovery-surgery-error-management-and-problem-solving-safety-critical … safety experts, this study adapted interventions from aviation crisis recovery for use in surgical error … https://psnet.ahrq.gov/issue/error-management-lessons-aviation https://psnet.ahrq.gov/issue/its-big-part-being-good-surgeons-surgical-trainees-perceptions-error-recovery-operating-room

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848358/psn-pdf
    May 03, 2023 - Identifying electronic health record contributions to diagnostic error in ambulatory settings through … Identifying electronic health record contributions to diagnostic error in ambulatory settings through … https://psnet.ahrq.gov/issue/identifying-electronic-health-record-contributions-diagnostic-error-ambulatory … from the CRICO malpractice insurance database to identify whether the EHR contributes to diagnostic error … EHR contributed to diagnostic error in 61% of claims, the majority in outpatient care, and 92% at the

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73526/psn-pdf
    July 28, 2021 - , human error is often a result of poor system design. … error. … Additionally, staff should be educated on error prevention strategies. … Implementing an error reporting process allows tracking and assessment of error trends that can be used … Report an Error. Available at: https://www.ismp.org/report- medication-error.

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848823/psn-pdf
    May 10, 2023 - Individual characteristics that promote or prevent psychological safety and error reporting in healthcare … Individual characteristics that promote or prevent psychological safety and error reporting in healthcare … https://psnet.ahrq.gov/issue/individual-characteristics-promote-or-prevent-psychological-safety-and-error … - reporting Psychological safety promotes speaking up and error reporting in the workplace, and many … This review highlights individual characteristics that encourage error reporting, (confidence and positive

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/842762/psn-pdf
    January 18, 2023 - Support for healthcare workers and patients after medical error through mutual healing: another step … Support for healthcare workers and patients after medical error through mutual healing: another step … https://psnet.ahrq.gov/issue/support-healthcare-workers-and-patients-after-medical-error-through-mutual … Healthcare workers (HCW) and patients can experience negative psychological impacts following medical error … the negative impact can be compounded when workers and patients are prevented from processing the error

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/50739/psn-pdf
    December 11, 2019 - Medical error and moral luck. December 11, 2019 Allhoff F. Medical Error and Moral Luck. … https://psnet.ahrq.gov/issue/medical-error-and-moral-luck Medical error is an important problem but … between medical errors and adverse events, challenges current ideas about what comprises a medical error … https://psnet.ahrq.gov/issue/medical-error-and-moral-luck https://psnet.ahrq.gov/issue/medical-error

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848035/psn-pdf
    April 26, 2023 - Diagnostic error among vulnerable populations presenting to the emergency department with cardiovascular … Diagnostic error among vulnerable populations presenting to the emergency department with cardiovascular … https://psnet.ahrq.gov/issue/diagnostic-error-among-vulnerable-populations-presenting-emergency- department-cardiovascular … In this review, researchers sought to identify frequency and causes of diagnostic error of vulnerable … Black patients presenting with cardiovascular symptoms had significantly higher odds of diagnostic error

  20. John M. Eisenberg Patient Safety Awards. Safety, effectiveness, and efficiency: a Web-based virtual anticoagulation clinic. | PSNet

    psnet.ahrq.gov/issue/john-m-eisenberg-patient-safety-awards-safety-effectiveness-and-efficiency-web-based-virtual
    September 13, 2023 - 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.
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