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psnet.ahrq.gov/issue/nurses-perception-medication-administration-errors-and-factors-associated-their-reporting
December 14, 2022 - The most common reason for not reporting MAE was leadership placing blame on the individual instead
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psnet.ahrq.gov/issue/five-reasons-optimism-world-patient-safety-day
March 30, 2022 - Commentary
Five reasons for optimism on World Patient Safety Day.
Citation Text:
Fontana G, Flott K, Dhingra-Kumar N, et al. Five reasons for optimism on World Patient Safety Day. Lancet. 2019;394(10203):993-995. doi:10.1016/S0140-6736(19)32134-8.
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psnet.ahrq.gov/issue/fallacious-reasoning-and-complexity-root-causes-clinical-inertia
June 17, 2020 - Commentary
Fallacious reasoning and complexity as root causes of clinical inertia.
Citation Text:
Miles RW. Fallacious reasoning and complexity as root causes of clinical inertia. J Am Med Dir Assoc. 2007;8(6):349-54.
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psnet.ahrq.gov/issue/raising-awareness-cognitive-biases-during-diagnostic-reasoning
February 03, 2021 - Study
Raising awareness of cognitive biases during diagnostic reasoning.
Citation Text:
van Geene K, de Groot E, Erkelens C, et al. Raising awareness of cognitive biases during diagnostic reasoning. Perspect Med Educ. 2016;5(3):182-5. doi:10.1007/s40037-016-0274-4.
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psnet.ahrq.gov/node/44648/psn-pdf
February 14, 2017 - Clinicians were required to provide a reason for overriding the allergy alert.
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psnet.ahrq.gov/issue/pediatric-radiology-malpractice-claims-characteristics-and-comparison-adult-radiology-claims
December 01, 2021 - error —particularly failure to diagnose congenital and developmental abnormalities—was the most common reason
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psnet.ahrq.gov/issue/higher-rates-misdiagnosis-pediatric-patients-versus-adults-hospitalized-imported-malaria
March 14, 2022 - One potential reason for these diagnostic errors was that children were much more likely to present
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psnet.ahrq.gov/issue/exploring-factors-drive-clinical-negligence-claims-stated-preferences-those-who-have
April 08, 2020 - Clinicians often cite fear of malpractice lawsuits as a reason to avoid apologizing after a patient
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psnet.ahrq.gov/issue/agreement-between-patient-reported-symptoms-and-their-documentation-medical-record
November 09, 2022 - physicians frequently did not document or address symptoms that patients had identified as the primary reason
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psnet.ahrq.gov/issue/communication-improved-implementation-obstetrical-version-world-health-organization-safe
February 02, 2022 - Investigators found better agreement about reason for cesarean deliveries among the obstetric, anesthesiology
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psnet.ahrq.gov/issue/10-medication-safety-tips-hospitalized-patients
February 06, 2019 - Recommendations include that patients know the reason they are taking each medication, speak up if any
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psnet.ahrq.gov/node/36605/psn-pdf
January 14, 2011 - drug-related-hospitalizations-tertiary-care-internal-medicine-service-canadian-
hospital
Medication errors are common in hospitalized patients, and are a common reason
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psnet.ahrq.gov/node/47127/psn-pdf
June 05, 2018 - This study describes an expert panel process to delineate how to include the indication—the
reason for
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psnet.ahrq.gov/issue/clinical-risk-management-enhancing-patient-safety-2nd-ed
May 20, 2019 - Its survey incorporates an essay on human error by James Reason.
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psnet.ahrq.gov/issue/error-disclosure-neonatal-intensive-care-multicentre-prospective-observational-study
November 29, 2023 - occurred overnight) and perceived lack of serious consequences for the infant as the most frequent reason
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psnet.ahrq.gov/issue/how-physicians-think-case-based-diagnostic-simulation-exercise
August 14, 2019 - This article describes the use of a case-based simulation to explore how physicians reason, create differential
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psnet.ahrq.gov/node/34794/psn-pdf
November 18, 2015 - November 18, 2015
Eagle CJ, Davies JM, Reason J.
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psnet.ahrq.gov/node/40102/psn-pdf
July 05, 2013 - The most common reason for unplanned ICU transfer was incorrect triage
(i.e., the patient should have
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psnet.ahrq.gov/issue/human-error-medicine
July 06, 2011 - Chapters include the Foreword by James Reason, Lucian Leape’s chapter on the preventability of medical
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psnet.ahrq.gov/node/44644/psn-pdf
February 14, 2017 - The study used the
electronic medical record in Quebec that required physicians to enter the reason