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141. 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: …

142. 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 …

143. Changes in prescription and over-the-counter medication and dietary supplement use among older adults in the United States, 2005 vs 2011. | PSNet
     psnet.ahrq.gov/issue/changes-prescription-and-over-counter-medication-and-dietary-supplement-use-among-older
     May 06, 2020 - Older adults commonly use over-the-counter medications and dietary supplements , which can lead to … June 19, 2019 Polypharmacy in the elderly--when good drugs lead to bad outcomes: a teachable

144. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49747/psn-pdf
     December 01, 2015 - Yet excessive false alarms may lead to unintended harm. … Since one monitor watcher is responsible for watching as many as 40 patients' data, only one ECG lead … If the telemetry algorithm uses just one ECG lead for analysis, this can more easily be misinterpreted … the responsible physician, the correct action would have been to search for another ECG monitoring lead … For example, the resident and nurse could have checked the patient's full diagnostic standard 12-lead

145. Effect of delays in the 2-week-wait cancer referral pathway during the COVID-19 pandemic on cancer survival in the UK: a modelling study. | PSNet
     psnet.ahrq.gov/issue/effect-delays-2-week-wait-cancer-referral-pathway-during-covid-19-pandemic-cancer-survival-uk
     October 21, 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

146. Dealing with the Unintended Consequences of Computerized Provider Order Entry (CPOE). | PSNet
     psnet.ahrq.gov/issue/dealing-unintended-consequences-computerized-provider-order-entry-cpoe
     December 28, 2020 - Copy URL July 4, 2007 This Web conference featured a discussion between the lead

147. Power of saying ‘I Don’t Know’: psychological safety and participatory strategies for healthcare leaders. | PSNet
     psnet.ahrq.gov/issue/power-saying-i-dont-know-psychological-safety-and-participatory-strategies-healthcare-leaders
     August 31, 2011 - BMJ Lead. 2024;Epub Jan 17. doi:10.1136/leader-2023-000906. … BMJ Lead . 2024; Epub Jan 17 . View more articles from the same authors. … BMJ Lead. 2024;Epub Jan 17. doi:10.1136/leader-2023-000906.

148. Roxane Laboratories initiates a nationwide voluntary recall of a single manufacturing lot of Azathioprine tablets in the U.S. and Puerto Rico. | PSNet
     psnet.ahrq.gov/issue/roxane-laboratories-initiates-nationwide-voluntary-recall-single-manufacturing-lot
     June 22, 2011 - Bottles may have been erroneously filled with another medication, which could lead to serious health … Differences in strength expression on product labels of compounders and conventional manufacturers may lead

149. Cognitive errors in diagnosis: instantiation, classification, and consequences. | PSNet
     psnet.ahrq.gov/issue/cognitive-errors-diagnosis-instantiation-classification-and-consequences
     June 21, 2016 - The authors conclude that cognitive errors lead to serious morbidity. … Classification of these error types may lead to future prevention efforts as a result of greater understanding

150. Drug shortages: effect on parenteral nutrition therapy. | PSNet
     psnet.ahrq.gov/issue/drug-shortages-effect-parenteral-nutrition-therapy
     June 20, 2018 - Shortages of medications and compounding components can lead to diversion from recommended treatment … October 3, 2018 The other opioid crisis: hospital shortages lead to patient pain, medical

151. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42588/psn-pdf
     September 18, 2013 - However, this process can lead to diagnostic error, as numerous cognitive biases can adversely affect … Pat Croskerry, the lead author of these articles, was interviewed by AHRQ WebM&M in 2010.

152. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46416/psn-pdf
     March 13, 2018 - has shown that prescribing opioids to opioid-naïve patients at the time of hospital discharge may lead … prescribing in the emergency department more often comported with CDC guidelines and was less likely to lead

153. Inadvertent Use of More Potent Acid Leads to Burn | PSNet
     psnet.ahrq.gov/web-mm/inadvertent-use-more-potent-acid-leads-burn
     November 01, 2023 - Inadvertent Use of More Potent Acid Leads to Burn Citation Text: Maibach HI. Inadvertent Use of More Potent Acid Leads to Burn. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2016. Copy Citation Format: Google Scholar B…

154. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/838220/psn-pdf
     September 27, 2019 - AHRQ, as one of the lead federal agencies in primary care research, funds research to understand how … AHRQ is the lead federal agency for patient safety research. … ’s, describing 7C’s,9 9C’s,10 or even 10C’s.11 These models all identify functions that ultimately lead … evidence- informed care, avoidance of low- value care Ineffective allocation of resources could lead … low or no value (cost- effectiveness) Engaging in value-based care Inefficient care delivery may lead

155. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47178/psn-pdf
     July 10, 2018 - The associated overtreatment that results from overdiagnosis can lead to increased financial stress … shown that breast cancer screening may identify lesions that are not clinically meaningful and may lead

156. A Fatal Twist in Pseudohyperkalemia | PSNet
     psnet.ahrq.gov/web-mm/fatal-twist-pseudohyperkalemia
     February 10, 2021 - His 12-lead electrocardiogram (ECG) demonstrated normal sinus rhythm and right bundle branch block (RBBB … Lewis, MD This case illustrates how the misinterpretation of a common laboratory complication can lead … In this 12-lead ECG, hypokalemia is evidenced by prominent U waves (red arrows) and T wave inversions … Clinicians should have a low threshold to repeat diagnostic testing such as routine bloodwork and 12-lead … WebM&M Cases Missing ECG and Missed Diagnosis Lead

157. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33808/psn-pdf
     May 01, 2016 - This desensitization can lead to longer response times or to missing important alarms. … Staff education Patient education Artifacts in the Waveform Waveform artifacts can be caused by poor lead … They can also lead to alarms when the monitor falsely perceives arrhythmias. … placement and change the electrodes daily.(6) In addition, proper care and maintenance of lead wires … Hospitals should not only have a policy for electrode changes, but also for monitoring and replacing lead

158. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44453/psn-pdf
     June 21, 2016 - collection There is a growing concern that lack of emphasis on performing the physical examination will lead … The lead author, Dr.

159. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37945/psn-pdf
     July 26, 2010 - crossing-quality-chasm-new-health-system-21st-century https://psnet.ahrq.gov/issue/improving-quality-health-care-who-will-lead … https://psnet.ahrq.gov/issue/improving-quality-health-care-who-will-lead https://psnet.ahrq.gov/primer

160. When we're all responsible for a patient's death, no one is. | PSNet
     psnet.ahrq.gov/issue/when-were-all-responsible-patients-death-no-one
     December 09, 2020 - 2020 Open Notes shines light on errors in patient medical records — will the new rule lead … April 20, 2022 Will prosecuting medical errors lead to a culture of silence?