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psnet.ahrq.gov/issue/cancer-drug-shortages-are-creating-dire-circumstances-some-patients
September 21, 2022 - Doctors worry that could lead to errors. … September 15, 2021
Covid-19 surge could lead to another drop in patient visits, doctors
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psnet.ahrq.gov/issue/quality-improvement-universal-protocol-use-office-based-gastrointestinal-procedure-units
November 16, 2022 - September 30, 2020
Does increased schedule flexibility lead to change? … September 23, 2020
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Unlabeled containers lead
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psnet.ahrq.gov/issue/cms-proposal-suppress-hospital-safety-data-angers-advocates-agency-says-covid-disruptions
June 15, 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/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/future-nursing-leading-change-advancing-health
July 27, 2011 - Book/Report
The Future of Nursing: Leading Change, Advancing Health.
Citation Text:
The Future of Nursing: Leading Change, Advancing Health. Institute of Medicine. Washington, DC: The National Academies Press: 2011.
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psnet.ahrq.gov/issue/misprogramming-pca-concentration-leads-dosing-errors
May 02, 2018 - Newspaper/Magazine Article
Misprogramming PCA concentration leads to dosing errors.
Citation Text:
Misprogramming PCA concentration leads to dosing errors. ISMP Medication Safety Alert! Acute Care Edition. August 28, 2008;13:1-3.
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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/45452/psn-pdf
August 24, 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/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
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psnet.ahrq.gov/node/866558/psn-pdf
August 21, 2024 - near-miss-and-maternal-sepsis-mortality-qualitative-study-survivors-and-
support-persons
Delayed diagnosis and management of sepsis can lead
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psnet.ahrq.gov/issue/medical-liability-climate-and-prospects-reform
September 29, 2017 - 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/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.
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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
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psnet.ahrq.gov/issue/teamwork-part-1-divided-we-fall-part-2-cursed-knowledge-building-culture-psychological-safety
August 02, 2015 - care becomes more complex, more teams and subspecialists are involved in a patient's care, which may lead … October 3, 2017
Did duty hour reform lead to better outcomes among the highest risk patients
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psnet.ahrq.gov/periodic-issue/periodic-issue-275
January 29, 2021 - Excess workload and burnout among nurses can compromise safe patient care and lead to adverse outcomes … Wrong-site surgeries can lead to serious patient harm and are considered never events by the National … and learning, leveraging patient engagement, and a national patient safety center to coordinate and lead … Emergency department (ED) overcrowding and prolonged ED stays can lead to adverse patient outcomes. … Wrong-site surgeries can lead to serious patient harm and are considered never events by the National
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psnet.ahrq.gov/periodic-issue/periodic-issue-389
April 26, 2023 - safety issues (e.g., potentially inappropriate prescribing, polypharmacy, adverse drug reactions) that lead … Changes in healthcare delivery due to the COVID-19 pandemic resulted in delays in care that can lead … Weight-based calculation errors and lack of weight documentation can lead to medication errors in pediatric … safety issues (e.g., potentially inappropriate prescribing, polypharmacy, adverse drug reactions) that lead … Failure to rescue refers to delayed or missed recognition of clinical deterioration, which can lead to
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psnet.ahrq.gov/primer/coronavirus-disease-2019-covid-19-and-diagnostic-error
July 30, 2020 - 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 the … Availability Bias The availability heuristic may lead clinicians to overdiagnose conditions that are … Premature closure may also lead clinicians to make a presumptive diagnosis of COVID-19 (allowing the
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psnet.ahrq.gov/training-catalog/johns-hopkins-patient-safety-specialization-courses
They will also lead a patient safety and/or quality improvement project, applying the methods described
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psnet.ahrq.gov/issue/communication-breakdown
September 21, 2005 - Linkedin
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This article reports on how langauge barriers and cultural misunderstandings can lead
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psnet.ahrq.gov/issue/medical-error-third-leading-cause-death-us
September 16, 2020 - 2025
The Financial and Human Cost of Medical Error... and How Massachusetts Can Lead