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201. Periodic Issue | PSNet
     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

202. Periodic Issue | PSNet
     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

203. Psn-Pdf (pdf file)
     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

204. 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

205. Coronavirus Disease 2019 (COVID-19) and Diagnostic Error | PSNet
     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

206. COVID-19 leads to increased need for dialysis machines. | PSNet
     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. Copy Citation Save Save to your library Print Dow…

207. 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

208. 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 … June 10, 2018 Administering a saline flush "site unseen" can lead to a wrong route error

209. 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

210. Psn-Pdf (pdf file)
     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

211. 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

212. Psn-Pdf (pdf file)
     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

213. 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

214. 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.

215. 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

216. 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 … May 7, 2014 Drawn curtains, muted alarms, and diverted attention lead to tragedy in the

217. Psn-Pdf (pdf file)
     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

218. 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

219. Psn-Pdf (pdf file)
     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

220. Psn-Pdf (pdf file)
     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