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psnet.ahrq.gov/issue/assessment-potential-impact-reminder-system-reduction-diagnostic-errors-quasi-experimental
April 19, 2011 - Study
Assessment of the potential impact of a reminder system on the reduction of diagnostic errors: a quasi-experimental study.
Citation Text:
Ramnarayan P, Roberts GC, Coren M, et al. Assessment of the potential impact of a reminder system on the reduction of diagnostic errors: a qua…
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psnet.ahrq.gov/issue/open-notes-shines-light-errors-patient-medical-records-will-new-rule-lead-flood-correction
March 27, 2024 - Newspaper/Magazine Article
Open Notes shines light on errors in patient medical records — will the new rule lead to a flood of correction requests?
Citation Text:
Open Notes shines light on errors in patient medical records — will the new rule lead to a flood of correction requests? Clar…
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psnet.ahrq.gov/issue/reliability-uncertainty-and-management-error-new-perspectives-covid-19-era
January 12, 2022 - Commentary
Reliability, uncertainty and the management of error: new perspectives in the COVID-19 era.
Citation Text:
Schulman PR. Reliability, uncertainty and the management of error: new perspectives in the COVID‐19 era. J Contingencies Crisis Manage. 2022;30(1):92-101. doi:10.1111/146…
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psnet.ahrq.gov/issue/antimicrobial-stewardship-and-patient-safety
May 15, 2024 - Commentary
Antimicrobial stewardship and patient safety.
Citation Text:
Zukowski CM. Antimicrobial Stewardship and Patient Safety. AORN J. 2016;104(4):354-356. doi:10.1016/j.aorn.2016.08.002.
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DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XM…
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psnet.ahrq.gov/issue/ems-crews-brought-patients-hospital-misplaced-breathing-tubes-none-them-survived
November 20, 2019 - Newspaper/Magazine Article
EMS crews brought patients to the hospital with misplaced breathing tubes. None of them survived
Citation Text:
EMS crews brought patients to the hospital with misplaced breathing tubes. None of them survived Arditi L. Peoples Public Radio. December 3, 2019.
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psnet.ahrq.gov/issue/understanding-human-factors-patient-safety-when-prescribing
June 15, 2022 - Newspaper/Magazine Article
Understanding human factors in patient safety when prescribing.
Citation Text:
Coon R, Holden K. Understanding human factors in patient safety when prescribing. Pharmaceutical Journal. September 2024;313(7989).
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psnet.ahrq.gov/issue/lessons-war-cancer-need-basic-research-safety
July 14, 2010 - Commentary
Lessons from the war on cancer: the need for basic research on safety.
Citation Text:
Lessons from the war on cancer: the need for basic research on safety. Cook RI. J Patient Saf. 2005.1(1):7-8
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psnet.ahrq.gov/node/865346/psn-pdf
March 27, 2024 - RaDonda Vaught says some system practices contributed
to fatal mistake.
March 27, 2024
Clark C. MedPage Today. March 14, 2024.
https://psnet.ahrq.gov/issue/vaught-says-some-system-practices-contributed-fatal-mistake
Stories from clinicians involved in errors provide unique insights into both the human an…
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psnet.ahrq.gov/node/72658/psn-pdf
January 20, 2021 - “I made a mistake!”: a narrative analysis of experienced
physicians' stories of preventable error.
January 20, 2021
Kandasamy S, Vanstone M, Colvin E, et al. “I made a mistake!”: a narrative analysis of experienced
physicians' stories of preventable error. J Eval Clin Pract. 2021;27(2):236-245. doi:10.1111/jep.1353…
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psnet.ahrq.gov/node/47957/psn-pdf
April 24, 2019 - A really stupid mistake: it does feel like a cop out to
blame my error on human frailty, but I'm afraid that's
exactly what it was.
April 24, 2019
Maskell G. A really stupid mistake: it does feel like a cop out to blame my error on human frailty, but I'm
afraid that's exactly what it was. BMJ. 2019;365:l1617. doi:…
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psnet.ahrq.gov/node/38894/psn-pdf
August 26, 2009 - Negotiating medical virtues: toward the development of a
physician mistake disclosure model.
August 26, 2009
Hannawa AF. Negotiating medical virtues: toward the development of a physician mistake disclosure
model. Health Comm. 2009;24(5):391-399. doi:10.1080/10410230903023279.
https://psnet.ahrq.gov/issue/negotiat…
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psnet.ahrq.gov/node/39296/psn-pdf
January 22, 2017 - Applying Lean Sigma solutions to mistake-proof the
chemotherapy preparation process.
January 22, 2017
Aboumatar HJ, Winner L, Davis RO, et al. Applying Lean Sigma solutions to mistake-proof the
chemotherapy preparation process. Jt Comm J Qual Patient Saf. 2010;36(2):79-86.
https://psnet.ahrq.gov/issue/applying-lea…
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psnet.ahrq.gov/node/39964/psn-pdf
January 04, 2011 - Fatal consequences of a simple mistake: how can a
patient be saved from inadvertent intrathecal vincristine?
January 4, 2011
Reddy K, Brown B, Nanda A. Fatal consequences of a simple mistake: how can a patient be saved from
inadvertent intrathecal vincristine? Clin Neurol Neurosurg. 2011;113(1):68-71.
doi:10.1016/…
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psnet.ahrq.gov/node/46037/psn-pdf
April 16, 2018 - 'If no-one stops me, I'll make the mistake again': changing
prescribing behaviours through feedback; a Perceptual
Control Theory perspective.
April 16, 2018
Ferguson J, Keyworth C, Tully MP. 'If no-one stops me, I'll make the mistake again': Changing prescribing
behaviours through feedback; A Perceptual Control Th…
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psnet.ahrq.gov/node/39241/psn-pdf
March 05, 2010 - Dealing honestly with an honest mistake.
March 5, 2010
Liang NL, Herring ME, Bush RL. Dealing honestly with an honest mistake. J Vasc Surg. 2010;51(2):494-5.
doi:10.1016/j.jvs.2009.11.001.
https://psnet.ahrq.gov/issue/dealing-honestly-honest-mistake
This case report describes a near miss involving a potential hepa…
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psnet.ahrq.gov/node/39771/psn-pdf
August 18, 2010 - Bearing witness to the ethics of practice: storying
physicians' medical mistake narratives.
August 18, 2010
Carmack HJ. Bearing witness to the ethics of practice: storying physicians' medical mistake narratives.
Health Commun. 2010;25(5):449-58. doi:10.1080/10410236.2010.484876.
https://psnet.ahrq.gov/issue/bearin…
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psnet.ahrq.gov/node/37148/psn-pdf
March 11, 2009 - CMS: your mistake, your problem.
March 11, 2009
Lubell J. CMS: your mistake, your problem. Eight hospital-acquired conditions won't be paid for. Modern
healthcare. 2007;37(33):10-1.
https://psnet.ahrq.gov/issue/cms-your-mistake-your-problem
This article discusses the challenges hospitals face in responding to rece…
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psnet.ahrq.gov/node/37044/psn-pdf
September 05, 2007 - Make no mistake about it: chain pharmacies are finding
innovative ways to combat medication errors.
September 5, 2007
Levy S. Drug Topics. July 9, 2007
https://psnet.ahrq.gov/issue/make-no-mistake-about-it-chain-pharmacies-are-finding-innovative-ways-
combat-medication
This article reports on ways in which chain …
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psnet.ahrq.gov/node/42753/psn-pdf
November 20, 2013 - Dealing with a medical mistake: should physicians
apologize to patients?
November 20, 2013
Tabler NG Jr.
https://psnet.ahrq.gov/issue/dealing-medical-mistake-should-physicians-apologize-patients
This article discusses how apologies address patients' needs when a medical mistake has occurred and
how such disclosur…
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psnet.ahrq.gov/node/39344/psn-pdf
March 03, 2010 - Mistake-proofing healthcare: why stopping processes
may be a good start.
March 3, 2010
Grout JR, Toussaint JS. Mistake-proofing healthcare: Why stopping processes may be a good start. Bus
Horiz. 2009;53(2):149-156. doi:10.1016/j.bushor.2009.10.007.
https://psnet.ahrq.gov/issue/mistake-proofing-healthcare-why-stopp…