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1601. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39110/psn-pdf
      June 10, 2018 - Order scanning systems may pull multiple pages through the scanner at the same time, leading to drug omissions. June 10, 2018 ISMP Medication Safety Alert! Acute Care Edition. November 5, 2009;14:1-3. https://psnet.ahrq.gov/issue/order-scanning-systems-may-pull-multiple-pages-through-scanner-same-time- leading-dru…

1602. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/46081/psn-pdf
      April 19, 2017 - Why are medical errors still a leading cause of death? April 19, 2017 Headley M. https://psnet.ahrq.gov/issue/why-are-medical-errors-still-leading-cause-death This magazine article explores the need for robust research and effective reporting to better understand the prevalence of medical errors and how to prevent…

1603. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/60309/psn-pdf
      May 06, 2020 - COVID-19 leads to increased need for dialysis machines. May 6, 2020 Mosley T. Here & Now. Boston Public Radio. April 27, 2020. https://psnet.ahrq.gov/issue/covid-19-leads-increased-need-dialysis-machines Comorbidities can result in unexpected care complexities. This article discusses an emerging challenge for …

1604. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44239/psn-pdf
      September 29, 2017 - When medical care leads to harm—difficulty finding words: a teachable moment. September 29, 2017 Chamberlain E, DiVeronica M, Segura R. When medical care leads to harm- difficulty finding words: a teachable moment. JAMA Intern Med. 2015;175(8):1271-1272. doi:10.1001/jamainternmed.2015.2334. https://psnet.ahrq.gov/…

1605. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/844553/psn-pdf
      February 15, 2023 - Mental health conditions leading cause of pregnancy- related deaths. February 15, 2023 Quick Safety. January 16 2023;(67):1-3. https://psnet.ahrq.gov/issue/mental-health-conditions-leading-cause-pregnancy-related-deaths Maternal safety is compromised by a range of social, cognitive, and clinical factors. This arti…

1606. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38598/psn-pdf
      June 03, 2010 - Leading successful rapid response teams: a multisite implementation evaluation. June 3, 2010 Donaldson N, Shapiro S, Scott M, et al. Leading successful rapid response teams: A multisite implementation evaluation. J Nurs Adm. 2009;39(4):176-81. doi:10.1097/NNA.0b013e31819c9ce9. https://psnet.ahrq.gov/issue/leading-…

1607. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73498/psn-pdf
      July 14, 2021 - Leaving a discontinued FentaNYL infusion attached to the patient leads to a tragic error July 14, 2021 ISMP Medication Safety Alert! Acute care edition. 2021;26(13);1-2. https://psnet.ahrq.gov/issue/leaving-discontinued-fentanyl-infusion-attached-patient-leads-tragic-error High-alert medication misadministration i…

1608. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/43201/psn-pdf
      May 21, 2014 - New HHS Data Shows Major Strides Made in Patient Safety, Leading to Improved Care and Savings. May 21, 2014 Washington, DC: US Department of Health and Human Services; May 7, 2014. https://psnet.ahrq.gov/issue/new-hhs-data-shows-major-strides-made-patient-safety-leading-improved- care-and-savings Comparing safety…

1609. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45357/psn-pdf
      October 09, 2016 - Leading article: how can I optimise my role as a leader within the surgical team? October 9, 2016 Green B, Mitchell DA, Stevenson P, et al. Leading article: how can I optimise my role as a leader within the surgical team? Br J Oral Maxillofac Surg. 2016;54(8):847-850. doi:10.1016/j.bjoms.2016.05.035. https://psnet…

1610. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/38051/psn-pdf
      May 05, 2018 - Misprogramming PCA concentration leads to dosing errors. May 5, 2018 ISMP Medication Safety Alert! Acute Care Edition. August 28, 2008;13:1-3. https://psnet.ahrq.gov/issue/misprogramming-pca-concentration-leads-dosing-errors This article describes dosing errors associated with improper concentration programming of…

1611. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/40055/psn-pdf
      December 01, 2010 - Parkland knee surgery done by doctor in training leads to amputation, questions. December 1, 2010 Egerton B. Dallas Morning News. November 14, 2010;A01. https://psnet.ahrq.gov/issue/parkland-knee-surgery-done-doctor-training-leads-amputation-questions This newspaper article investigates how surgical errors and pos…

1612. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45113/psn-pdf
      May 11, 2016 - Medical error—the third leading cause of death in the US. May 11, 2016 Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ. 2016;353:i2139. doi:10.1136/bmj.i2139. https://psnet.ahrq.gov/issue/medical-error-third-leading-cause-death-us How many patients die each year due to preventabl…

1613. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/39825/psn-pdf
      June 10, 2018 - Electronic prescribing vulnerabilities: height and weight mix-up leads to dosing error. June 10, 2018 ISMP Medication Safety Alert! Acute care edition. August 26, 2010;15:1-3. https://psnet.ahrq.gov/issue/electronic-prescribing-vulnerabilities-height-and-weight-mix-leads-dosing-error This article discusses a case …

1614. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/73097/psn-pdf
      March 31, 2011 - The Future of Nursing: Leading Change, Advancing Health. March 31, 2011 Institute of Medicine. Washington, DC: The National Academies Press: 2011. https://psnet.ahrq.gov/issue/future-nursing-leading-change-advancing-health The effective engagement of nursing is key to patient safety and care quality improvement. T…

1615. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45005/psn-pdf
      May 04, 2016 - Leading High-Reliability Organizations in Healthcare. May 4, 2016 Morrow R. Boca Raton, FL: Productivity Press; 2016. ISBN: 9781466594883. https://psnet.ahrq.gov/issue/leading-high-reliability-organizations-healthcare High reliability has been recently adopted as a goal for health care. This book reviews the primar…

1616. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44363/psn-pdf
      May 05, 2018 - Selection of incorrect medication pump leads to chemotherapy overdose. May 5, 2018 ISMP Canada. August 26, 2015;15:1-4. https://psnet.ahrq.gov/issue/selection-incorrect-medication-pump-leads-chemotherapy-overdose Checklists are cognitive aids that help clinicians remember important steps to ensure safe practice. I…

1617. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/34659/psn-pdf
      April 07, 2010 - Leading change: why transformation efforts fail. April 7, 2010 Kotter JP. Harvard Bus Rev  1995;73(2);59-67. https://psnet.ahrq.gov/issue/leading-change-why-transformation-efforts-fail Kotter, a professor at Harvard Business School, outlines the eight stages of a successful change process, as well a…

1618. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/45565/psn-pdf
      May 24, 2017 - Leading a Culture of Safety: a Blueprint for Success. May 24, 2017 Chicago, IL: American College of Healthcare Executives, National Patient Safety Foundation's Lucian Leape Institute; 2017. https://psnet.ahrq.gov/issue/leading-culture-safety-blueprint-success Health care leadership plays an undeniable role in sust…

1619. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44303/psn-pdf
      January 10, 2018 - Leading Health Care Transformation: A Primer for Clinical Leaders. January 10, 2018 Joshi M, Erb N, Zhang S, Sikka R. Boca Raton, FL: CRC Press; 2015. ISBN: 9781498700184. https://psnet.ahrq.gov/issue/leading-health-care-transformation-primer-clinical-leaders Leadership can enable the change needed to address heal…

1620. Psn-Pdf (pdf file)
      psnet.ahrq.gov/node/44183/psn-pdf
      November 03, 2015 - The absence of a drug–disease interaction alert leads to a child's death. November 3, 2015 ISMP Medication Safety Alert! Acute Care Edition. May 21, 2015;20:1-4. https://psnet.ahrq.gov/issue/absence-drug-disease-interaction-alert-leads-childs-death The disabling of alerts due to alarm fatigue can hinder the abilit…