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- Communication Improvement 1
- Education and Training 5
- Error Reporting and Analysis 1
- Human Factors Engineering 2
- Legal and Policy Approaches
- Quality Improvement Strategies 2
- Device-related Complications 1
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Identification Errors 1
- Medical Complications 1
- Medication Safety 3
- Nonsurgical Procedural Complications 2
- Psychological and Social Complications 2
- Surgical Complications 1
Search results for "Cognitive Errors ("Mistakes")"
- Cognitive Errors ("Mistakes")
- Credentialing, Licensure, and Discipline
Journal Article > Review
Wu AW, Kavanagh KT, Pronovost PJ, Bates DW. J Patient Saf. 2014;10:181-185.
In light of an unreported conflict of interest that might have affected recommendations for chlorhexidine use to reduce risk of central line–associated infections, this review examines articles written or coauthored by Dr. Charles Denham to determine whether undeclared conflicts of interest could have influenced conclusions, selections, and recommendations in published research. The authors emphasize the need to identify and address conflicts of interest and outline strategies to reduce risk of undisclosed conflicts which may in turn affect validity of published evidence.
Cases & Commentaries
- Web M&M
Nancy Spector, PhD, RN ; March 2011
While caring for a complex patient in the surgical intensive care unit, a nurse incorrectly set up the continuous renal replacement therapy (CRRT) machine, raising questions about how new nurses should be trained in high-risk procedures.
Tarkan L. New York Times. January 25, 2011:D1.
This newspaper article reports on the aging of the physician population and its potential risks to patient safety.
Journal Article > Government Resource
Acute Hepatitis C virus infections attributed to unsafe injection practices at an endoscopy clinic—Nevada, 2007.
Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. 2008;57:513-517.
This report further discusses the investigation of a Hepatitis C outbreak that resulted from unsafe injection practices at an endoscopy clinic.
Associated Press. MSNBC. November 27, 2007.
This news article reports repeated incidents of wrong-side surgery at the same facility, and state and hospital reactions to the errors.
Ostrov BF. San Jose Mercury News. October 26, 2007;Local section:1B.
This article reports that, despite facing state sanctions and fines for its role in three fatal medication errors since 2004, a violating hospital was slow to retrain its pharmacy technicians.
Paul R. Drug Topics. September 17, 2007;151:10.
This article reports on an error for which criminal charges were filed against the pharmacist and his license was revoked, prompting concern from pharmacy experts that such action could discourage reporting.
Fernandez J. Drug Topics. May 7, 2007.
This article discusses a chemotherapy overdose that led to a child's death and the punitive measures taken against the pharmacist involved.
Breast Cancer Services in Trafford and North Manchester. An Investigation Into The Circumstances Surrounding A Serious Clinical Incident In Symptomatic Breast Services – The Baker Report.
Baker M. Manchester, England: NHS North West; February 2007.
This report shares findings from an investigation into individual and system failures that contributed to a radiologist misreading mammograms for a 2-year period.
Cases & Commentaries
- Web M&M
Robert S. Wigton, MD; October 2003
Misplacement of an NG tube sends charcoal into the lung; the patient dies of complications.