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psnet.ahrq.gov/issue/promethazine-conundrum-iv-can-hurt-more-im-injection
November 13, 2018 - Interruptions lead to errors and unfinished…wait, what was I doing? … December 21, 2009
Tenfold errors can lead to tragedy.
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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.
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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.
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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.
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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
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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
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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
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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
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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
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psnet.ahrq.gov/issue/shortage-everything-except-errors-harm-associated-drug-shortages
February 13, 2019 - Interruptions lead to errors and unfinished…wait, what was I doing? … 10, 2018
Mismatched prescribing and pharmacy templates for parenteral nutrition (PN) lead
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psnet.ahrq.gov/issue/raising-index-suspicion-red-flags-represent-credible-threats-patient-safety
February 13, 2019 - Interruptions lead to errors and unfinished…wait, what was I doing? … 21, 2012
Mismatched prescribing and pharmacy templates for parenteral nutrition (PN) lead
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psnet.ahrq.gov/issue/good-intention-uncertain-outcomeour-take-physician-dispensing-offices-and-clinics
February 13, 2019 - Interruptions lead to errors and unfinished…wait, what was I doing? … 10, 2018
Mismatched prescribing and pharmacy templates for parenteral nutrition (PN) lead
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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.
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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.
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psnet.ahrq.gov/node/42582/psn-pdf
September 18, 2013 - This commentary recommends an approach to examine laboratory testing and identify weaknesses that
may lead
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psnet.ahrq.gov/issue/are-national-efforts-reduce-drug-name-confusion-paying
December 27, 2018 - Interruptions lead to errors and unfinished…wait, what was I doing? … , 2018
Smart pump custom concentrations without hard "low concentration" alerts can lead
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psnet.ahrq.gov/issue/vaught-says-some-system-practices-contributed-fatal-mistake
September 29, 2021 - Author(s)
Open Notes shines light on errors in patient medical records — will the new rule lead … May 15, 2024
Will prosecuting medical errors lead to a culture of silence?
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psnet.ahrq.gov/issue/anesthesiologist-group-says-hospitals-can-prevent-fatal-errors-vanderbilts
June 01, 2022 - 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?
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psnet.ahrq.gov/node/43695/psn-pdf
August 02, 2015 - systems (which
use an adjudication process rather than usual courts) will all play a larger role and lead … Formation of accountable care organizations may
lead to reform in the liability system such that organizations
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psnet.ahrq.gov/issue/urgent-need-improve-health-care-quality-institute-medicine-national-roundtable-health-care
May 27, 2015 - Without prescribing a specific approach, the authors call on health care professionals to take the lead … January 23, 2019
Improving the quality of health care: who will lead?