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101. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/50934/psn-pdf
     February 26, 2020 - Resident in Quality and Safety (CRQS) program alumni suggests that such programs can teach residents to lead … and engage other residents in patient safety and ultimately lead to a workforce fostering a culture

102. Incorrect use of smart infusion pump in the operating room (OR) leads to milrinone overdose. | PSNet
     psnet.ahrq.gov/issue/incorrect-use-smart-infusion-pump-operating-room-or-leads-milrinone-overdose
     June 03, 2020 - Lack of familiarity with smart pumps can lead to user error  and patient harm. … The article describes conditions that lead to a programing mistake .

103. Leading your organization to high reliability. | PSNet
     psnet.ahrq.gov/issue/leading-your-organization-high-reliability
     August 18, 2021 - Commentary Leading your organization to high reliability. Citation Text: Kemper C, Boyle DK. Leading your organization to high reliability. Nurs Manag. 2009;40(4):14-18. doi:10.1097/01.NUMA.0000349684.24165.68. Copy Citation Format: DOI Google Scholar PubMed BibTeX EndNot…

104. Roll-Out Diagram Generic (pdf file)
     psnet.ahrq.gov/sites/default/files/2021-09/Roll-out%20diagram%20generic.pdf
     January 01, 2021 - leads or physician champions request program roll-out for unit/department Resilience program lead … Anticipate and Plan stress inoculation discussions with dept/ unit members (ongoing) Dept/nursing lead

105. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/851919/psn-pdf
     August 02, 2023 - such as barcode scanning, is a recognized method for improving medication safety, but poor design may lead … primer/alert-fatigue https://psnet.ahrq.gov/issue/unreadable-barcodes-and-multiple-barcodes-packages-can-lead-errors

106. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/48126/psn-pdf
     August 14, 2019 - a leadership intervention to improve quality and safety in nursing homes and home care (the SAFE-LEAD … of a leadership intervention to improve quality and safety in nursing homes and home care (the SAFE-LEAD

107. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/837145/psn-pdf
     May 18, 2022 - - administration-errors Polypharmacy is an established problem among older adult patients and can lead … psnet.ahrq.gov/web-mm/polypharmacy https://psnet.ahrq.gov/issue/polypharmacy-elderly-when-good-drugs-lead-bad-outcomes-teachable-moment

108. Residents feel unprepared and unsupervised as leaders of cardiac arrest teams in teaching hospitals: a survey of internal medicine residents. | PSNet
     psnet.ahrq.gov/issue/residents-feel-unprepared-and-unsupervised-leaders-cardiac-arrest-teams-teaching-hospitals
     February 07, 2024 - Housestaff traditionally lead cardiac arrest resuscitation ("code blue") teams at academic institutions … found that most respondents felt that ACLS training alone did not leave them adequately prepared to lead

109. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/849319/psn-pdf
     May 24, 2023 - issue/attitudes-clinicians-and-patient-safety-culture-and-after-arrive-trial Cesarean delivery can lead … /psnet.ahrq.gov/primer/maternal-safety https://psnet.ahrq.gov/issue/quality-improvement-initiatives-lead-reduction-nulliparous-term-singleton-vertex-cesarean

110. Pediatric weight errors and resultant medication dosing errors in the emergency department. | PSNet
     psnet.ahrq.gov/issue/pediatric-weight-errors-and-resultant-medication-dosing-errors-emergency-department
     August 04, 2021 - Weight-based dosing errors can lead to adverse drug events . … This retrospective study found that weight-related errors are rare but did lead to medication dosing

111. Diagnostic errors--The next frontier for patient safety. | PSNet
     psnet.ahrq.gov/issue/diagnostic-errors-next-frontier-patient-safety
     October 14, 2020 - This commentary discusses individual and systems factors that lead to diagnostic error and proposes … An AHRQ WebM&M  perspective discussed cognitive biases that lead to diagnostic error.

112. The fallacy of a single diagnosis. | PSNet
     psnet.ahrq.gov/issue/fallacy-single-diagnosis
     October 05, 2022 - accept a diagnosis before it has been confirmed and alternative diagnoses have been explored and can lead … Findings suggest that bias can lead individual to overlook the likelihood of COVID-19 when an alternative

113. Authentic leadership at the Cleveland Clinic: psychological safety in the midst of crisis. | PSNet
     psnet.ahrq.gov/issue/authentic-leadership-cleveland-clinic-psychological-safety-midst-crisis
     October 19, 2022 - BMJ Lead. 2023;7(3):196-202. doi:10.1136/leader-2022-000626. … BMJ Lead . 2023; 7 (3) :196-202 . View more articles from the same authors. … BMJ Lead. 2023;7(3):196-202. doi:10.1136/leader-2022-000626.

114. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/848314/psn-pdf
     May 03, 2023 - safety issues (e.g., potentially inappropriate prescribing, polypharmacy, adverse drug reactions) that lead … medication-errors-and-adverse-drug-events https://psnet.ahrq.gov/issue/polypharmacy-elderly-when-good-drugs-lead-bad-outcomes-teachable-moment

115. Master of Healthcare Quality and Safety. | PSNet
     psnet.ahrq.gov/issue/master-healthcare-quality-and-safety
     February 05, 2014 - This one-year degree program will train clinicians and health care executives to lead safety and … Meyer, MD, MSc June 1, 2016 Clinical faculty: taking the lead in teaching quality

116. System planning for modern-day Just Culture to mitigate worker distress and second victim response. | PSNet
     psnet.ahrq.gov/issue/system-planning-modern-day-just-culture-mitigate-worker-distress-and-second-victim-response
     July 19, 2023 - BMJ Lead. 2024;8(2):149-152. doi:10.1136/leader-2023-000811. … BMJ Lead . 2024; 8 (2) :149-152 . View more articles from the same authors. … BMJ Lead. 2024;8(2):149-152. doi:10.1136/leader-2023-000811.

117. Diagnostic delays in infectious diseases. | PSNet
     psnet.ahrq.gov/issue/diagnostic-delays-infectious-diseases
     December 15, 2021 - Delayed diagnosis of infectious diseases can lead to serious patient harm . … April 15, 2020 Diagnostic errors that lead to inappropriate antimicrobial use.

118. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/837299/psn-pdf
     June 01, 2022 - new-index-obstetrics-safety-and-quality-care-integrating-cesarean-delivery- rates-maternal-and Cesarean delivery can lead … /psnet.ahrq.gov/primer/maternal-safety https://psnet.ahrq.gov/issue/quality-improvement-initiatives-lead-reduction-nulliparous-term-singleton-vertex-cesarean

119. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60825/psn-pdf
     August 19, 2020 - Results suggest that, for many cancer patients, treatment delays of 2-6 months will lead to a substantial … Results also indicate that even small delays (e.g., 2 months) can lead to substantial survival decrements

120. What I wish I’d known: how experienced physician managers diagnose, treat and prevent disruptive behaviour. | PSNet
     psnet.ahrq.gov/issue/what-i-wish-id-known-how-experienced-physician-managers-diagnose-treat-and-prevent-disruptive
     September 23, 2020 - BMJ Lead. 2023;7(2):128-132. doi:10.1136/leader-2022-000615. … BMJ Lead . 2023; 7 (2) :128-132 . View more articles from the same authors. … BMJ Lead. 2023;7(2):128-132. doi:10.1136/leader-2022-000615.