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181. A multi-hospital before–after observational study using a point-prevalence approach with an infusion safety intervention bundle to reduce intravenous medication administration errors. | PSNet
     psnet.ahrq.gov/issue/multi-hospital-after-observational-study-using-point-prevalence-approach-infusion-safety
     January 23, 2017 - rate and medication error rate per 100 medication administrations decreased, the intervention did not lead … May 16, 2018 The other opioid crisis: hospital shortages lead to patient pain, medical

182. Evaluation of outcomes from a national patient-initiated second-opinion program. | PSNet
     psnet.ahrq.gov/issue/evaluation-outcomes-national-patient-initiated-second-opinion-program
     July 15, 2015 - Diagnostic errors can lead to delayed or incorrect treatments, resulting in serious patient harms. … April 8, 2018 Diagnostic errors that lead to inappropriate antimicrobial use.

183. Psn-Pdf (pdf file)
     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

184. Hospira Carpuject pre-filled cartridges—drug alert: products may contain more than the intended fill volume. | PSNet
     psnet.ahrq.gov/issue/hospira-carpuject-pre-filled-cartridges-drug-alert-products-may-contain-more-intended-fill
     August 05, 2020 - , 2012 Codeine use in certain children after tonsillectomy and/or adenoidectomy may lead … Differences in strength expression on product labels of compounders and conventional manufacturers may lead

185. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866847/psn-pdf
     September 25, 2024 - The evidence-based approach is true when it comes to preventing errors and mistakes that can lead to … processes that reduce the probability of experiencing errors and catching errors that occur before they lead … culture in what they say and do is critical to ensuring that a zero harm goal doesn't potentially lead … that CEO left, those organizations lost those gains in a matter of months when the new CEO didn’t lead

186. Spotlight
     psnet.ahrq.gov/sites/default/files/2024-08/spotlight_case_a_fatal_twist_in_pseudohyperkalemia_slides.pptx
     January 01, 2024 - His 12-lead electrocardiogram (ECG) demonstrated normal sinus rhythm and right bundle branch block (RBBB … Overview 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 … Take Home Points 27 Take-Home Points 28 Failure to recognize lab values affected by hemolysis can lead

187. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60722/psn-pdf
     February 06, 2023 - global pandemic, delayed diagnosis of infection with SARS-CoV-2, the virus that causes COVID-19, may lead … However, these same heuristics that support “fast and frugal” decision-making can lead to diagnostic … To avoid such errors, it is useful to understand why these heuristics potentially lead to biases in … In current circumstances, this cognitive (anchoring) bias may lead clinicians to miss the diagnosis of … Premature closure may also lead clinicians to make a presumptive diagnosis of COVID-19 (allowing the

188. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/838222/psn-pdf
     September 28, 2022 - them out to do things they don’t need to do, and avoid unnecessary tests or treatments that might lead … So, I think we’re well positioned to lead patient safety efforts. … I think primary care has an opportunity to lead the patient safety effort or to claim it as part of … We need to lead the charge in making sure that those organizations have the information they need to … Those transitions are important, and I think primary care can lead by example and demand from our

189. Why are medical errors still a leading cause of death? | PSNet
     psnet.ahrq.gov/issue/why-are-medical-errors-still-leading-cause-death
     September 13, 2017 - Newspaper/Magazine Article Why are medical errors still a leading cause of death? Citation Text: Why are medical errors still a leading cause of death? Headley M. Copy Citation Save Save to your library Print Download PDF Share Facebook …

190. Selection of incorrect medication pump leads to chemotherapy overdose. | PSNet
     psnet.ahrq.gov/issue/selection-incorrect-medication-pump-leads-chemotherapy-overdose
     September 09, 2015 - Newspaper/Magazine Article Selection of incorrect medication pump leads to chemotherapy overdose. Citation Text: Selection of incorrect medication pump leads to chemotherapy overdose. ISMP Canada. August 26, 2015;15:1-4. Copy Citation Save Save to your library …

191. Leading Health Care Transformation: A Primer for Clinical Leaders. | PSNet
     psnet.ahrq.gov/issue/leading-health-care-transformation-primer-clinical-leaders
     April 12, 2017 - Book/Report Leading Health Care Transformation: A Primer for Clinical Leaders. Citation Text: Leading Health Care Transformation: A Primer for Clinical Leaders. Joshi M, Erb N, Zhang S, Sikka R. Boca Raton, FL: CRC Press; 2015. ISBN: 9781498700184. Copy Citation Save …

192. Hospitals win safety award for simple changes.  | PSNet
     psnet.ahrq.gov/issue/hospitals-win-safety-award-simple-changes
     September 06, 2006 - Copy Citation Related Resources From the Same Author(s) Tenfold errors can lead … June 10, 2018 Loud wake-up call: unlabeled containers lead to patient’s death.

193. Promethazine conundrum: IV can hurt more than IM injection! | PSNet
     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.

194. A clinical reminder about the safe use of insulin vials. | PSNet
     psnet.ahrq.gov/issue/clinical-reminder-about-safe-use-insulin-vials
     June 10, 2018 - Resources From the Same Author(s) Drawn curtains, muted alarms, and diverted attention lead … May 7, 2014 Administering a saline flush "site unseen" can lead to a wrong route error

195. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/854849/psn-pdf
     October 31, 2023 - of underused interventions.2 However, they are known to facilitate other types of errors that may lead … Electronic propagation of less obviously incorrect information from another patient’s record could lead … This practice might also lead to undertreatment by misleading the clinician about a contraindication … Thoughtful use of copy/paste can save time and keystrokes, but it can lead to medical errors and patient … However, inappropriate use of these tools may lead to patient harm.

196. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867698/psn-pdf
     October 01, 2024 - toolkit-mrsa-prevention-icu-non-icu-settings Methicillin-resistant Staphylococcus aureus (MRSA) infections can lead

197. Medical Mistakes and What Doctors Can Learn From Pilots | PSNet
     psnet.ahrq.gov/training-catalog/medical-mistakes-and-what-doctors-can-learn-pilots
     July 21, 2025 - events that discusses strategies to avoid medical mistakes, how to recognize cognitive biases that can lead

198. Preventing medication errors by empowering patients. | PSNet
     psnet.ahrq.gov/issue/preventing-medication-errors-empowering-patients
     September 28, 2016 - 2020 Open Notes shines light on errors in patient medical records — will the new rule lead … June 10, 2018 Error-prone conditions that lead to student nurse-related errors.

199. Fatal PCA adverse events continue to happen...better patient monitoring is essential to prevent harm. | PSNet
     psnet.ahrq.gov/issue/fatal-pca-adverse-events-continue-happenbetter-patient-monitoring-essential-prevent-harm
     June 10, 2018 - Related Resources From the Same Author(s) Administering a saline flush "site unseen" can lead … June 10, 2018 Drawn curtains, muted alarms, and diverted attention lead to tragedy in

200. A shortage of everything except errors: harm associated with drug shortages. | PSNet
     psnet.ahrq.gov/issue/shortage-everything-except-errors-harm-associated-drug-shortages
     February 13, 2019 - 21, 2012 Mismatched prescribing and pharmacy templates for parenteral nutrition (PN) lead … Interruptions lead to errors and unfinished…wait, what was I doing?