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141. 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

142. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46510/psn-pdf
     January 01, 2019 - pediatric-weight-errors-and-resultant-medication-dosing-errors-emergency- department Weight-based dosing errors can lead … This retrospective study found that weight- related errors are rare but did lead to medication dosing

143. In Conversation With... Jack Westfall, MD, MPH | PSNet
     psnet.ahrq.gov/perspective/conversation-jack-westfall-md-mph
     September 28, 2022 - So, I think we’re well positioned to lead patient safety efforts. … Primary care needs to lead the proactive sharing of information when we transition patients and refer … We need to lead the charge in making sure that those organizations have the information they need to … JW: I want to just reiterate the point that primary care and family physicians can lead the efforts … AHRQ is the lead federal agency for patient safety research.

144. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37026/psn-pdf
     September 15, 2011 - residents-feel-unprepared-and-unsupervised-leaders-cardiac-arrest-teams- teaching-hospitals Housestaff traditionally lead … found that most respondents felt that ACLS training alone did not leave them adequately prepared to lead

145. 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

146. 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.

147. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38491/psn-pdf
     January 31, 2011 - 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.

148. Harm From Alarm Fatigue | PSNet
     psnet.ahrq.gov/web-mm/harm-alarm-fatigue
     February 14, 2018 - 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

149. Defining, estimating, and communicating overdiagnosis in cancer screening. | PSNet
     psnet.ahrq.gov/issue/defining-estimating-and-communicating-overdiagnosis-cancer-screening
     October 13, 2018 - The associated overtreatment that results from overdiagnosis can lead to increased financial stress and … shown that breast cancer screening may identify lesions that are not clinically meaningful and may lead

150. Opioid prescribing for opioid-naive patients in emergency departments and other settings: characteristics of prescriptions and association with long-term use. | PSNet
     psnet.ahrq.gov/issue/opioid-prescribing-opioid-naive-patients-emergency-departments-and-other-settings
     August 29, 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

151. Missed diagnoses of acute cardiac ischemia in the emergency department. | PSNet
     psnet.ahrq.gov/issue/missed-diagnoses-acute-cardiac-ischemia-emergency-department
     November 30, 2012 - Missed or delayed diagnosis of cardiovascular disease can lead to adverse patient outcomes . … 2018 WebM&M Cases Missing ECG and Missed Diagnosis Lead

152. Distracting communications in the operating theatre. | PSNet
     psnet.ahrq.gov/issue/distracting-communications-operating-theatre
     August 18, 2017 - communication to errors, the authors speculate that the large number of "case-irrelevant communications" could lead … April 10, 2019 Inadequate preoperative team briefings lead to more intraoperative adverse

153. What price must we pay for safety? Excessive cost of EPINEPHrine auto-injectors leads to error-prone use of ampuls or vials and unprepared consumers. | PSNet
     psnet.ahrq.gov/issue/what-price-must-we-pay-safety-excessive-cost-epinephrine-auto-injectors-leads-error-prone-use
     September 14, 2016 - administration methods used to reduce device costs can introduce heightened potential for dosing errors and lead

154. 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?

155. 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.

156. 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

157. Comparing hospital leadership and front-line workers' perceptions of patient safety culture: an unbalanced panel study. | PSNet
     psnet.ahrq.gov/issue/comparing-hospital-leadership-and-front-line-workers-perceptions-patient-safety-culture
     June 07, 2016 - BMJ Lead. 2024;8(8):335-339. doi:10.1136/leader-2023-000922. … BMJ Lead . 2024; 8 (8) :335-339 . View more articles from the same authors. … BMJ Lead. 2024;8(8):335-339. doi:10.1136/leader-2023-000922.

158. When work harms: how better understanding of avoidable employee harm can improve employee safety, patient safety and healthcare quality. | PSNet
     psnet.ahrq.gov/issue/when-work-harms-how-better-understanding-avoidable-employee-harm-can-improve-employee-safety
     December 16, 2015 - BMJ Lead. 2024;8(1):59-62. doi:10.1136/leader-2023-000849. … BMJ Lead . 2024; 8 (1) :59-62 . View more articles from the same authors. … BMJ Lead. 2024;8(1):59-62. doi:10.1136/leader-2023-000849.

159. Interprofessional model on speaking up behaviour in healthcare professionals: a qualitative study. | PSNet
     psnet.ahrq.gov/issue/interprofessional-model-speaking-behaviour-healthcare-professionals-qualitative-study
     December 21, 2017 - BMJ Lead. 2022;6(1):15-19. doi:10.1136/leader-2020-000407. … BMJ Lead . 2022; 6 (1) :15-19 . View more articles from the same authors. … BMJ Lead. 2022;6(1):15-19. doi:10.1136/leader-2020-000407.

160. Report links Georgia's abortion ban to preventable deaths. | PSNet
     psnet.ahrq.gov/issue/report-links-georgias-abortion-ban-preventable-deaths
     November 13, 2024 - How Abortion Bans Lead to Preventable Deaths. … How Abortion Bans Lead to Preventable Deaths.