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401. 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

402. 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.

403. Spotlight Case July 2008 (ppt file)
     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

404. 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

405. 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

406. 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

407. 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

408. Microsoft Word - deliverable45_2.doc (pdf file)
     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

409. 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

410. Right Patient, Wrong Sample | PSNet
     psnet.ahrq.gov/web-mm/right-patient-wrong-sample
     June 01, 2004 - 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

411. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37424/psn-pdf
     May 25, 2011 - Responding to serious medical error in general practice—consequences for the GPs involved: analysis … Responding to serious medical error in general practice--consequences for the GPs involved: analysis … -75-cases Physicians were asked to voluntarily report the "most serious error" they had been involved … Most reported that their patients still trusted them after the error, especially if the physician disclosed … the error.

412. Strengthen your resolve: no unlabeled containers anywhere, ever! | PSNet
     psnet.ahrq.gov/issue/strengthen-your-resolve-no-unlabeled-containers-anywhere-ever
     November 16, 2015 - 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.

413. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33620/psn-pdf
     September 01, 2005 - team with expertise in the area of investigation whose members were NOT directly involved with the error … While they do mention conducting "interviews with key staff involved in the error," they do not propose … My interpretation is that this includes those directly involved in the error. … can have a hard time separating themselves from the error and focusing on systems solutions. … The viewpoint of the health care provider involved in an error, however, is critical.

414. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34650/psn-pdf
     April 21, 2015 - Human error: models and management. April 21, 2015 Reason J. Human error: models and management. … https://psnet.ahrq.gov/issue/human-error-models-and-management The author discusses concepts of human … error, contrasting the person approach with a system approach in understanding the differing philosophies … of error management. … several background concepts, including the “Swiss cheese” model of system accidents, the components of error

415. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38943/psn-pdf
     November 25, 2009 - Medical error reporting, patient safety, and the physician. … Medical Error Reporting, Patient Safety, and the Physician. … to report errors, due in part to logistical barriers but also due to cultural barriers that inhibit error … Interestingly, physicians who had themselves been the victim of an error, or who had a family member … injured as a result of an error, were more likely to both report errors and describe witnessing errors

416. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45455/psn-pdf
     June 29, 2017 - JAMA professionalism: disclosure of medical error. June 29, 2017 Levinson W, Yeung J, Ginsburg S. … Disclosure of Medical Error. JAMA. 2016;316(7):764-5. doi:10.1001/jama.2016.9136. … https://psnet.ahrq.gov/issue/jama-professionalism-disclosure-medical-error Disclosing medical errors … Recommended best practices for error disclosure include being honest about what happened, explicitly … stating that an error occurred, and explaining to the patient any relevant specific information that

417. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44518/psn-pdf
     January 22, 2016 - Embracing errors in simulation-based training: the effect of error training on retention and transfer … Embracing Errors in Simulation-Based Training: The Effect of Error Training on Retention and Transfer … https://psnet.ahrq.gov/issue/embracing-errors-simulation-based-training-effect-error-training-retention-and … - transfer This study suggests that incorporating error training into curricula may result in better … Trainees performed similarly on immediate postcourse tests, but the group that included error training

418. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43983/psn-pdf
     February 05, 2016 - Near-miss transcription errors: a comparison of reporting rates between a novel error-reporting mechanism … Near-miss transcription errors: a comparison of reporting rates between a novel error-reporting mechanism … This observational study compared error detection rates for medication transcription errors between … a hospital's formal reporting system and a passive error identification mechanism embedded in ordering … reporting mechanism identified fewer errors than electronic surveillance, emphasizing the need to build error

419. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34126/psn-pdf
     July 20, 2012 - National Coordinating Council for Medication Error Reporting and Prevention. … July 20, 2012 National Coordinating Council for Medication Error Reporting and Prevention. … https://psnet.ahrq.gov/issue/national-coordinating-council-medication-error-reporting-and-prevention … National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) coordinates a … medication error.

420. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43419/psn-pdf
     October 20, 2014 - Impact of a reengineered electronic error-reporting system on medication event reporting and care process … Impact of a reengineered electronic error-reporting system on medication event reporting and care process … https://psnet.ahrq.gov/issue/impact-reengineered-electronic-error-reporting-system-medication-event- … This pre-post study sought to determine the impact of a reengineered medication error reporting approach … The intervention led to increased error reporting, with the majority of errors being near-misses.