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psnet.ahrq.gov/node/43177/psn-pdf
May 14, 2014 - Disclosing medical errors to patients: effects of nonverbal
involvement.
May 14, 2014
Hannawa AF. Disclosing medical errors to patients: effects of nonverbal involvement. Patient Educ Couns.
2014;94(3):310-313. doi:10.1016/j.pec.2013.11.007.
https://psnet.ahrq.gov/issue/disclosing-medical-errors-patients-effects-n…
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psnet.ahrq.gov/node/47611/psn-pdf
January 23, 2019 - Drug and opioid-involved overdose deaths- United States,
2013-2017.
January 23, 2019
Scholl L, Seth P, Kariisa M, et al. Drug and Opioid-Involved Overdose Deaths - United States, 2013-2017.
MMWR Morb Mortal Wkly Rep. 2018;67(5152):1419-1427. doi:10.15585/mmwr.mm675152e1.
https://psnet.ahrq.gov/issue/drug-and-opioi…
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psnet.ahrq.gov/node/35312/psn-pdf
January 02, 2017 - Medication errors involving wrong administration
technique.
January 2, 2017
Santell JP, Cousins DD. Medication Errors Involving Wrong Administration Technique. The Joint
Commission Journal on Quality and Patient Safety. 2016;31(9). doi:10.1016/s1553-7250(05)31068-3.
https://psnet.ahrq.gov/issue/medication-errors-i…
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psnet.ahrq.gov/node/46707/psn-pdf
October 13, 2018 - Medication errors involving nursing students: a
systematic review.
October 13, 2018
Asensi-Vicente J, Jiménez-Ruiz I, Vizcaya-Moreno F. Medication Errors Involving Nursing Students: A
Systematic Review. Nurse Educ. 2018;43(5):E1-E5. doi:10.1097/NNE.0000000000000481.
https://psnet.ahrq.gov/issue/medication-errors-i…
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psnet.ahrq.gov/node/42503/psn-pdf
September 18, 2013 - The patient is in: patient involvement strategies for
diagnostic error mitigation.
September 18, 2013
McDonald KM, Bryce CL, Graber ML. The patient is in: patient involvement strategies for diagnostic error
mitigation. BMJ Qual Saf. 2013;22 Suppl 2:ii33-ii39. doi:10.1136/bmjqs-2012-001623.
https://psnet.ahrq.gov/i…
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psnet.ahrq.gov/node/37585/psn-pdf
April 29, 2010 - Medication errors involving patient-controlled analgesia.
April 29, 2010
Hicks RW, Sikirica V, Nelson W, et al. Medication errors involving patient-controlled analgesia. Am J Health
Syst Pharm. 2008;65(5):429-40. doi:10.2146/ajhp070194.
https://psnet.ahrq.gov/issue/medication-errors-involving-patient-controlled-a…
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psnet.ahrq.gov/node/39387/psn-pdf
July 23, 2014 - Medication errors involving oral chemotherapy.
July 23, 2014
Weingart SN, Toro J, Spencer J, et al. Medication errors involving oral chemotherapy. Cancer.
2010;116(10):2455-2464. doi:10.1002/cncr.25027.
https://psnet.ahrq.gov/issue/medication-errors-involving-oral-chemotherapy
Widely publicized errors associated w…
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psnet.ahrq.gov/issue/barriers-and-facilitators-chemotherapy-patients-engagement-medical-error-prevention
November 02, 2010 - Study
Barriers and facilitators to chemotherapy patients' engagement in medical error prevention.
Citation Text:
Schwappach DLB, Wernli M. Barriers and facilitators to chemotherapy patients' engagement in medical error prevention. Ann Oncol. 2011;22(2):424-30. doi:10.1093/annonc/mdq346…
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psnet.ahrq.gov/node/40441/psn-pdf
July 02, 2014 - A novel approach to increase residents' involvement in
reporting adverse events.
July 2, 2014
Scott DR, Weimer M, English C, et al. A novel approach to increase residents' involvement in reporting
adverse events. Acad Med. 2011;86(6):742-746. doi:10.1097/ACM.0b013e318217e12a.
https://psnet.ahrq.gov/issue/novel-app…
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psnet.ahrq.gov/perspective/rethinking-root-cause-analysis
August 21, 2016 - implementation of the corrective actions is often incomplete; and, at the end of the RCA process (which often involves
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psnet.ahrq.gov/web-mm/medication-reconciliation-pitfalls
May 01, 2006 - The Commentary This error involves a system failure in the proper identification, documentation, and
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psnet.ahrq.gov/node/41998/psn-pdf
January 30, 2013 - Involving Patients in Improving Safety.
January 30, 2013
London, UK: The Health Foundation; January 2013.
https://psnet.ahrq.gov/issue/involving-patients-improving-safety
This review analyzes research on engaging patients in safety improvement and details which strategies are
most effective.
https://psnet.ahrq.go…
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psnet.ahrq.gov/node/42068/psn-pdf
April 09, 2013 - Wisdom through adversity: learning and growing in the
wake of an error.
April 9, 2013
Plews-Ogan M, Owens JE, May NB. Wisdom through adversity: learning and growing in the wake of an
error. Patient Educ Couns. 2013;91(2):236-42. doi:10.1016/j.pec.2012.12.006.
https://psnet.ahrq.gov/issue/wisdom-through-adversity-l…
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psnet.ahrq.gov/node/40916/psn-pdf
August 01, 2016 - Disclosure of medical errors involving gametes and
embryos.
August 1, 2016
Ethics Committee of the American Society for Reproductive Medicine. Fertil Steril. 2016;106:59-63.
https://psnet.ahrq.gov/issue/disclosure-medical-errors-involving-gametes-and-embryos
This publication advocates for open disclosure of errors…
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psnet.ahrq.gov/node/36861/psn-pdf
November 23, 2016 - Patients as Partners: How to Involve Patients and
Families in Their Own Care.
November 23, 2016
McGreevey M. Oakbrook Terrace, IL: Joint Commission Resources: 2006. ISBN 9780866889964.
https://psnet.ahrq.gov/issue/patients-partners-how-involve-patients-and-families-their-own-care
This book illustrates how health c…
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psnet.ahrq.gov/perspective/conversation-withjoseph-britto-md
February 01, 2007 - The first involves perfecting performance through feedback, and the other focuses on improving physicians … This occurs automatically (subconsciously) and involves recognizing patterns (schema) they have seen
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psnet.ahrq.gov/perspective/diagnostic-errors-medicine-what-do-doctors-and-umpires-have-common
February 01, 2007 - The first involves perfecting performance through feedback, and the other focuses on improving physicians … This occurs automatically (subconsciously) and involves recognizing patterns (schema) they have seen
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psnet.ahrq.gov/node/49603/psn-pdf
June 01, 2010 - Fatal Error in Neonate: Does "Just Culture" Provide an
Answer?
June 1, 2010
Dekker SWA. Fatal Error in Neonate: Does "Just Culture" Provide an Answer? PSNet [internet]. 2010.
https://psnet.ahrq.gov/web-mm/fatal-error-neonate-does-just-culture-provide-answer
Case Objectives
Describe the just culture approach to in…
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psnet.ahrq.gov/web-mm/staggered-sensitivity-results
May 01, 2013 - One system involves Therapeutic Antibiotic Monitoring (TAM) alerts in which coordinated pharmacy and
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psnet.ahrq.gov/node/49769/psn-pdf
September 01, 2016 - The Commentary
by Jennifer Morris and Marie Bismark, MD
This case involves a doctor who was the subject