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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.
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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.
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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
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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
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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
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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
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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.
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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
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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
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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
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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.
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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
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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.
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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
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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
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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
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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
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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.
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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
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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?