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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/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/node/837308/psn-pdf
June 01, 2022 - delays-diagnosis-treatment-and-surgery-root-causes-actions-taken-and-
recommendations
Delays in diagnosis and treatment can lead
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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
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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/issue/covid-19-leads-increased-need-dialysis-machines
April 29, 2020 - Audiovisual
COVID-19 leads to increased need for dialysis machines.
Citation Text:
COVID-19 leads to increased need for dialysis machines. Mosley T. Here & Now. Boston Public Radio. April 27, 2020.
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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
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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 … June 10, 2018
Administering a saline flush "site unseen" can lead to a wrong route error
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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
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psnet.ahrq.gov/node/36146/psn-pdf
February 05, 2019 - The material also includes risk assessments
to identify space concerns that could lead to unsafe conditions
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psnet.ahrq.gov/node/74259/psn-pdf
January 19, 2022 - psnet.ahrq.gov/issue/diagnostic-reasoning-cardiovascular-medicine
Misdiagnosis of heart failure can lead
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psnet.ahrq.gov/node/47280/psn-pdf
October 15, 2018 - master-healthcare-quality-and-safety
This one-year degree program will train clinicians and health care executives to lead
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psnet.ahrq.gov/node/866118/psn-pdf
June 12, 2024 - This report analyzed 92 investigations that provided safety
recommendations to improve midwifery-lead
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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.
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psnet.ahrq.gov/issue/survey-results-community-liaison-programs-decrease-hospital-readmissions
June 10, 2018 - Resources From the Same Author(s)
Drawn curtains, muted alarms, and diverted attention lead … June 10, 2018
Administering a saline flush "site unseen" can lead to a wrong route error
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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 … May 7, 2014
Drawn curtains, muted alarms, and diverted attention lead to tragedy in the
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psnet.ahrq.gov/node/849139/psn-pdf
May 17, 2023 - intended-and-unintended-consequences-changes-opioid-prescribing-practices-postsurgical-acute
https://psnet.ahrq.gov/issue/other-opioid-crisis-hospital-shortages-lead-patient-pain-medical-errors
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psnet.ahrq.gov/node/838184/psn-pdf
September 28, 2022 - /hidden-risk-wheelchair-use
Medical devices intended to improve patient safety can unintentionally lead
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psnet.ahrq.gov/node/47435/psn-pdf
November 07, 2018 - https://psnet.ahrq.gov/issue/cognitive-bias-clinical-medicine
Cognitive biases can lead to unnecessary
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psnet.ahrq.gov/node/864855/psn-pdf
March 20, 2024 - use of specialized, stable operating
room teams and use of specialty-dedicated operating rooms can lead