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201. Survey results: community liaison programs to decrease hospital readmissions. | PSNet
     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

202. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43265/psn-pdf
     February 15, 2024 - five-medication-safety-tips-older-adults Highlighting how aging affects medication absorption that may lead

203. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44288/psn-pdf
     March 21, 2024 - psnet.ahrq.gov/issue/prevention-adverse-drug-events-hospitals Unsafe medication systems in hospitals can lead

204. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866618/psn-pdf
     December 31, 2024 - His 12-lead electrocardiogram (ECG) demonstrated normal sinus rhythm and right bundle branch block ( … Lewis, MD 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 Failure to recognize lab values affected by hemolysis can lead to serious patient outcomes

205. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/72689/psn-pdf
     January 29, 2021 - salt and sodium bicarbonate mouthwash and pain control.4 A timely diagnosis of oral mucositis will lead … to Horwtiz et al.5 Unfortunately, blood cultures are low in yield6 and a false positive can often lead … radiologic tests.”9 The reflexive ordering of tests without a proper in-person bedside assessment may lead … to more patient handoffs.11 Frequent and poor handoffs can lead to more cross-cover questions, calls … is still hope that creating a better culture of safety will hopefully encourage more teamwork and lead

206. 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 …

207. 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 …

208. 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 …

209. Clinical Decision Support Systems | PSNet
     psnet.ahrq.gov/primer/clinical-decision-support-systems
     December 15, 2024 - Excessive warnings or poorly targeted reminders can easily lead to alert fatigue for clinicians, diminishing … to learn from examples, rather than being preprogrammed with rules based on human inputs—will likely lead … the methods used to develop recommendations and rigorous evaluation of new programs to ensure they lead

210. Electrocardiogram Results: ***READ ME*** | PSNet
     psnet.ahrq.gov/web-mm/electrocardiogram-results-read-me
     May 01, 2019 - Delays in making this diagnosis can lead to significant adverse outcomes for patients. … This can lead to an erroneous diagnosis of acute myocardial infarction ( Table ) or other clinically … Subarachnoid hemorrhage • Metabolic disturbances, such as hyperkalemia • Cardiomyopathy • Lead … 2019 WebM&M Cases Missing ECG and Missed Diagnosis Lead

211. Reduce readmissions with pharmacy programs that focus on transitions from the hospital to the community. | PSNet
     psnet.ahrq.gov/issue/reduce-readmissions-pharmacy-programs-focus-transitions-hospital-community
     September 26, 2016 - Interruptions lead to errors and unfinished…wait, what was I doing? … 8, 2016 Mismatched prescribing and pharmacy templates for parenteral nutrition (PN) lead

212. A mislabeling event with batched drugs: the unintended consequences of practice changes. | PSNet
     psnet.ahrq.gov/issue/mislabeling-event-batched-drugs-unintended-consequences-practice-changes
     May 07, 2014 - June 10, 2018 Administering a saline flush "site unseen" can lead to a wrong route error … 10, 2018 Mismatched prescribing and pharmacy templates for parenteral nutrition (PN) lead

213. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/74259/psn-pdf
     January 19, 2022 - psnet.ahrq.gov/issue/diagnostic-reasoning-cardiovascular-medicine Misdiagnosis of heart failure can lead

214. Psn-Pdf (pdf file)
     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

215. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/838184/psn-pdf
     September 28, 2022 - /hidden-risk-wheelchair-use Medical devices intended to improve patient safety can unintentionally lead

216. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866118/psn-pdf
     June 12, 2024 - This report analyzed 92 investigations that provided safety recommendations to improve midwifery-lead

217. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33725/psn-pdf
     February 01, 2012 - be taken in GME to improve patient safety.(3,4) Most recently, ACGME, largely following the IOM's lead … In other words, inadequate supervision may lead to unintended harm to patients in the present, but excessive … supervision may lead to unintended harm to patients in the future by limiting the amount of independent … compliance with practice guidelines, decrease complications and mortality rates in the operating room, and lead

218. Drug shortages continue to compromise patient care. | PSNet
     psnet.ahrq.gov/issue/drug-shortages-continue-compromise-patient-care
     February 24, 2016 - , 2018 Smart pump custom concentrations without hard "low concentration" alerts can lead … June 27, 2018 The other opioid crisis: hospital shortages lead to patient pain, medical

219. Kadcyla (ado-trastuzumab emtansine): drug safety communication—potential medication errors resulting from name confusion. | PSNet
     psnet.ahrq.gov/issue/kadcyla-ado-trastuzumab-emtansine-drug-safety-communication-potential-medication-errors
     October 09, 2013 - , 2013 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

220. Survey results: smart pump data analytics pump metrics that should be monitored to improve safety. | PSNet
     psnet.ahrq.gov/issue/survey-results-smart-pump-data-analytics-pump-metrics-should-be-monitored-improve-safety
     August 08, 2018 - , 2018 Smart pump custom concentrations without hard "low concentration" alerts can lead … , 2018 Smart pump custom concentrations without hard "low concentration" alerts can lead