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361. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43910/psn-pdf
     November 23, 2016 - Error disclosure and family members' reactions: does the type of error really matter? … Error disclosure and family members' reactions: does the type of error really matter? … https://psnet.ahrq.gov/issue/error-disclosure-and-family-members-reactions-does-type-error-really-matter … In this study, Italian physicians were videotaped in a simulated scenario of error disclosure to a … https://psnet.ahrq.gov/issue/error-disclosure-and-family-members-reactions-does-type-error-really-matter

362. 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

363. Microsoft Word - deliverable45_01.doc (pdf file)
     hcup-us.ahrq.gov/reports/methods/2008_01.pdf
     January 01, 2008 - Percentage of Discharges (Standard Error) Average Length of Stay in Days (Standard Error) … ) Percentage of Discharges (Standard Error) Average Length of Stay in Days (Standard Error … ) Percentage of Discharges (Standard Error) Average Length of Stay in Days (Standard Error … ) Percentage of Discharges (Standard Error) Average Length of Stay in Days (Standard Error … ) Percentage of Discharges (Standard Error) Average Length of Stay in Days (Standard Error)

364. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44657/psn-pdf
     November 11, 2015 - Understanding and confronting our mistakes: the epidemiology of error in radiology and strategies for … error reduction. … error reduction. … https://psnet.ahrq.gov/issue/understanding-and-confronting-our-mistakes-epidemiology-error-radiology-and-strategies-error … https://psnet.ahrq.gov/issue/understanding-and-confronting-our-mistakes-epidemiology-error-radiology-and-strategies-error

365. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34691/psn-pdf
     May 18, 2016 - Error in medicine. May 18, 2016 Leape L. Error in medicine. JAMA. 1994;272(23):1851-1857. … https://psnet.ahrq.gov/issue/error-medicine Leape discusses how traditional methods of error reduction … With reference to Reason, he briefly reviews the cognitive psychology of human error, distinguishing … between performance and error at the schematic or "skill" level, where an error is a "slip" (or "lapse … "), and at the rule-based or "knowledge" level, where an error is a "mistake."

366. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/841156/psn-pdf
     October 10, 2010 - “Those found responsible have been sacked”: some observations on the usefulness of error. … “Those found responsible have been sacked”: some observations on the usefulness of error. … https://psnet.ahrq.gov/issue/those-found-responsible-have-been-sacked-some-observations-usefulness- error … https://psnet.ahrq.gov/issue/new-view-human-error-origins-ambiguities-successes-and-critiques https: … /issue/human-error https://psnet.ahrq.gov/issue/role-error-organizing-behaviour

367. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42238/psn-pdf
     July 02, 2014 - Teaching medical error disclosure to physicians-in- training: a scoping review. … Teaching medical error disclosure to physicians-in-training: a scoping review. … an error has occurred, many physicians choose their words carefully—failing to explicitly describe … the error, acknowledge responsibility, or express sympathy to patients. … A difficult case of error disclosure is discussed in an AHRQ WebM&M commentary.

368. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49680/psn-pdf
     March 01, 2013 - This kind of error can be difficult to identify because it can be confused with other error types, such … The error classification system above was proposed to improve measurement of error rates, clinical impact … Error prevention requires a multifaceted approach. … Additionally, using root cause analysis to identify sources of error has proven to decrease error.(11 … Error types in anatomic pathology.

369. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42067/psn-pdf
     March 18, 2013 - Methodological variations and their effects on reported medication administration error rates. … Methodological variations and their effects on reported medication administration error rates. … errors: variations in the methods used to measure errors can result in widely differing estimates of error … series of recommendations for standardizing measurement and reporting of medication administration error … rates, and medication error measurement standards have been developed for medication reconciliation

370. Action needed to prevent dangerous heparin-insulin confusion. | PSNet
     psnet.ahrq.gov/issue/action-needed-prevent-dangerous-heparin-insulin-confusion
     May 07, 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. … June 16, 2019 ISMP medication error report analysis.

371. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38142/psn-pdf
     April 30, 2014 - Medical error disclosure among pediatricians: choosing carefully what we might say to parents. … Medical Error Disclosure Among Pediatricians. … https://psnet.ahrq.gov/issue/medical-error-disclosure-among-pediatricians-choosing-carefully-what-we- … might-say-parents Studies of medical error disclosure have demonstrated that, while physicians support … In this study, pediatricians were presented with error scenarios and asked to describe what they would

372. 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.

373. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49409/psn-pdf
     July 01, 2003 - 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.

374. Pathologic Mistake | PSNet
     psnet.ahrq.gov/web-mm/pathologic-mistake
     February 15, 2010 - This kind of error can be difficult to identify because it can be confused with other error types, such … The error classification system above was proposed to improve measurement of error rates, clinical impact … Error prevention requires a multifaceted approach. … Additionally, using root cause analysis to identify sources of error has proven to decrease error.( 11 … Error types in anatomic pathology.

375. 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

376. 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

377. 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

378. 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

379. 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

380. 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