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  1. 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
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39457/psn-pdf
    April 12, 2011 - Disclosure of medical error to parents and paediatric patients: assessment of parents' attitudes and … Disclosure of medical error to parents and paediatric patients: assessment of parents' attitudes and … https://psnet.ahrq.gov/issue/disclosure-medical-error-parents-and-paediatric-patients-assessment-parents … narrative-review-do-state-laws-make-it-easier-say-im-sorry https://psnet.ahrq.gov/issue/parental-preferences-error-disclosure-reporting-and-legal-action-after-medical-error-care … https://psnet.ahrq.gov/web-mm/wrong-shot-error-disclosure
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43447/psn-pdf
    November 20, 2015 - Evaluating the effect of safety culture on error reporting: a comparison of managerial and staff perspectives … Evaluating the effect of safety culture on error reporting: a comparison of managerial and staff perspectives … https://psnet.ahrq.gov/issue/evaluating-effect-safety-culture-error-reporting-comparison-managerial-and … - staff-perspectives Voluntary error reporting is a critical mechanism for identifying patient safety … Error feedback and organizational learning were most associated with perceptions of frequent error reporting
  4. 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
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49450/psn-pdf
    June 01, 2004 - The Wrong Shot: Error Disclosure June 1, 2004 Gallagher TH, Levinson W. … The Wrong Shot: Error Disclosure. PSNet [internet]. 2004. … When a harmful error takes place, patients first want an explicit, jargon-free statement that an error … Institutions can take several steps to improve error disclosure. … Moral courage in medicine--disclosing medical error.
  6. psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.239_slideshow.ppt
    May 01, 2011 - Spotlight Case July 2008 Spotlight Case Duty to Disclose Someone Else’s Error * * Source and … A 62-year-old woman with skin cancer who experienced wrong-site surgery: review of medical error. … Liability claims and costs before and after implementation of a medical error disclosure program. … Talking with Patients and Families about Medical Error: A Guide for Education and Practice. … , optimal strategies involve full collaboration in error investigation and joint disclosure if an error
  7. 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.
  8. 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
  9. 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
  10. 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
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/49527/psn-pdf
    December 01, 2006 - Studies are difficult to compare because of large variations in error detection methods and error definitions … This front-end error checking missed the mislabeling error in this case, probably because the requisition … Specific Errors in This Case The particular error in this case is a mislabeling error occurring outside … The Field Guide to Human Error Investigations. … error ___ Human error ___ Instrument error ___ Reagent error ___ Other analytic error Postanalytic
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36536/psn-pdf
    January 10, 2011 - What do family physicians consider an error? … What do family physicians consider an error? A comparison of definitions and physician perception. … The investigators conducted surveys and literature review to explore how family physicians identified error … and found little agreement on what constituted error both in the field and the research base. … https://psnet.ahrq.gov//#error
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44390/psn-pdf
    July 18, 2016 - Pediatricians' attitudes toward error disclosure. … Pediatricians' Attitudes Toward Error Disclosure. … errors to patients is considered the standard of care, but many physicians remain uncomfortable with error … This survey study sought to assess pediatricians' perceptions of error disclosure to patients and their … with parents in choosing to disclose errors to children and believed parents should be present during error
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35839/psn-pdf
    March 28, 2011 - Patient assessments of a hypothetical medical error: effects of health outcome, disclosure, and staff … Patient assessments of a hypothetical medical error: effects of health outcome, disclosure, and staff … https://psnet.ahrq.gov/issue/patient-assessments-hypothetical-medical-error-effects-health-outcome- … disclosure-and-staff This study presented a medication error scenario to a group of recently discharged … https://psnet.ahrq.gov//#error
  15. 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
  16. hcup-us.ahrq.gov/reports/methods/2010_03.pdf
    January 01, 2010 - ) 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
  17. 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.
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46906/psn-pdf
    May 30, 2018 - Making an infusion error: the second victims of infusion therapy-related medication errors. … Making an Infusion Error: The Second Victims of Infusion Therapy-Related Medication Errors. … https://psnet.ahrq.gov/issue/making-infusion-error-second-victims-infusion-therapy-related-medication … Respondents who self-reported an error frequently blamed themselves. … https://psnet.ahrq.gov/issue/medical-error-second-victim https://psnet.ahrq.gov/issue/medical-error-second-victim
  19. psnet.ahrq.gov/issue/safety-intravenous-drug-delivery-systems-update-current-issues-1999-consensus-development
    May 13, 2020 - 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.
  20. psnet.ahrq.gov/issue/impact-standard-medication-chart-prescribing-errors-and-after-audit
    May 02, 2012 - 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.