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psnet.ahrq.gov/issue/medical-error-disclosure-gap-between-attitude-and-practice
November 13, 2024 - Study
Medical error disclosure: the gap between attitude and practice.
Citation Text:
Ghalandarpoorattar SM, Kaviani A, Asghari F. Medical error disclosure: the gap between attitude and practice. Postgrad Med J. 2012;88(1037):130-3. doi:10.1136/postgradmedj-2011-130118.
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psnet.ahrq.gov/issue/applying-lean-methods-improve-quality-and-safety-surgical-sterile-instrument-processing
September 16, 2015 - Study
Applying Lean methods to improve quality and safety in surgical sterile instrument processing.
Citation Text:
Blackmore C, Bishop R, Luker S, et al. Applying lean methods to improve quality and safety in surgical sterile instrument processing. Jt Comm J Qual Patient Saf. 2013;39(…
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psnet.ahrq.gov/issue/why-it-so-hard-reduce-harm-medicines
April 28, 2021 - Commentary
Why is it so hard to reduce harm from medicines?
Citation Text:
Rochford A. Why is it so hard to reduce harm from medicines? Future Healthc J. 2024;11(4):100205. doi:10.1016/j.fhj.2024.100205.
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psnet.ahrq.gov/issue/use-cascading-a3s-drive-systemwide-improvement
January 29, 2015 - Commentary
Use of cascading A3s to drive systemwide improvement.
Citation Text:
Winner LE, Burroughs TJ, Cady-Reh JA, et al. Use of Cascading A3s to Drive Systemwide Improvement. Jt Comm J Qual Patient Saf. 2017;43(8):422-428. doi:10.1016/j.jcjq.2017.03.011.
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psnet.ahrq.gov/issue/surgical-complications-disclosing-adverse-events-and-medical-errors
September 23, 2020 - Commentary
Surgical complications: disclosing adverse events and medical errors.
Citation Text:
Wang AS, Eisen DB. Surgical complications: disclosing adverse events and medical errors. J Am Acad Dermatol. 2013;68(1):144-6. doi:10.1016/j.jaad.2012.09.008.
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psnet.ahrq.gov/issue/disclosing-medical-errors-patients-effects-nonverbal-involvement
June 14, 2017 - Study
Disclosing medical errors to patients: effects of nonverbal involvement.
Citation Text:
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.
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psnet.ahrq.gov/issue/shedding-light-dark-side-doctor-patient-interactions-verbal-and-nonverbal-messages-physicians
June 14, 2017 - Study
Shedding light on the dark side of doctor–patient interactions: verbal and nonverbal messages physicians communicate during error disclosures.
Citation Text:
Hannawa AF. Shedding light on the dark side of doctor-patient interactions: verbal and nonverbal messages physicians commu…
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psnet.ahrq.gov/issue/mask-shortage-straps-pharmacists-who-need-them-keep-medicines-pure
August 02, 2023 - Newspaper/Magazine Article
Mask shortage straps pharmacists who need them to keep medicines pure.
Citation Text:
Mask shortage straps pharmacists who need them to keep medicines pure. Jewett C, Lupkin S. Health Shots. National Public Radio. March 20, 2020.
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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…