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101. 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.

102. 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

103. Medication Mix-Up Leads to Patient Death | PSNet
     psnet.ahrq.gov/web-mm/medication-mix-leads-patient-death
     July 08, 2022 - Increased stress caused by understaffing can lead to coping strategies that manifest as safety workaround … Workarounds occur within healthcare systems and may lead to deviations from protocols while providing … The modern healthcare system has non-routine episodes of medication administration that can lead to errors … medication administration were split among individuals, increasing the opportunity for cognitive biases to lead

104. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/838135/psn-pdf
     January 01, 2023 - 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

105. 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

106. Did duty hour reform lead to better outcomes among the highest risk patients? | PSNet
     psnet.ahrq.gov/issue/did-duty-hour-reform-lead-better-outcomes-among-highest-risk-patients
     January 13, 2010 - Study Did duty hour reform lead to better outcomes among the highest risk patients … Did duty hour reform lead to better outcomes among the highest risk patients? … Did duty hour reform lead to better outcomes among the highest risk patients?

107. 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

108. 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

109. 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.

110. 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

111. 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

112. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47372/psn-pdf
     January 01, 2019 - safety culture, health information technology implementation, and medical office problems that could lead … Safety Culture, Health Information Technology Implementation, and Medical Office Problems That Could Lead … Incorrect or delayed diagnoses can subject patients to unnecessary testing and delays in care that lead

113. 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

114. 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

115. 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

116. 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

117. Exploring challenges in quality and safety work in nursing homes and home care - a case study as basis for theory development. | PSNet
     psnet.ahrq.gov/issue/exploring-challenges-quality-and-safety-work-nursing-homes-and-home-care-case-study-basis
     August 14, 2019 - A part of the SAFE-LEAD program to promote safety culture in Norwegian nursing homes and home … of a leadership intervention to improve quality and safety in nursing homes and home care (the SAFE-LEAD

118. Leading change: why transformation efforts fail. | PSNet
     psnet.ahrq.gov/issue/leading-change-why-transformation-efforts-fail
     March 03, 2021 - Commentary Classic Leading change: why transformation efforts fail. Citation Text: Leading change: why transformation efforts fail. Kotter JP. Harvard Bus Rev  1995;73(2);59-67. Copy Citation Save Save to your library …

119. An Incomplete Anesthesia History Leads to Adverse Outcomes | PSNet
     psnet.ahrq.gov/web-mm/incomplete-anesthesia-history-leads-adverse-outcomes
     January 29, 2021 - An Incomplete Anesthesia History Leads to Adverse Outcomes Citation Text: Bohringer C. An Incomplete Anesthesia History Leads to Adverse Outcomes. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2022. Copy Citation Format: …

120. Investigating the influence of selected leadership styles on patient safety and quality of care: a systematic review and meta-analysis. | PSNet
     psnet.ahrq.gov/issue/investigating-influence-selected-leadership-styles-patient-safety-and-quality-care-systematic
     October 07, 2020 - BMJ Lead. 2024;18(3):208-214. doi:10.1136/leader-2023-000846. … BMJ Lead . 2024; 18 (3) :208-214 . View more articles from the same authors. … BMJ Lead. 2024;18(3):208-214. doi:10.1136/leader-2023-000846.