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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/840477/psn-pdf
    November 30, 2022 - common-and-consequential-fractures-should-not-be-missed-children Diagnostic errors involving pediatric musculoskeletal radiographs can lead

  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74100/psn-pdf
    November 24, 2021 - pediatric-medication-errors-and-reduction-strategies-perioperative-period Pediatric medication errors during anesthesia can lead

  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47709/psn-pdf
    August 07, 2019 - They uncovered a significant number of medication discrepancies that could lead to adverse drug events

  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/867650/psn-pdf
    January 01, 2022 - issue/opioid-deprescribing-toolkit Sudden discontinuation of long-term prescription opioid use can lead

  5. 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

  6. Psn-Pdf (pdf file)

    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

  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47953/psn-pdf
    January 01, 2021 - impact-medication-reviews-delivered-community-pharmacist-elderly-patients-polypharmacy-meta https://psnet.ahrq.gov/issue/polypharmacy-elderly-when-good-drugs-lead-bad-outcomes-teachable-moment

  8. Medical device alarm safety in hospitals. | PSNet

    psnet.ahrq.gov/issue/medical-device-alarm-safety-hospitals
    December 23, 2016 - , 2018 Smart pump custom concentrations without hard "low concentration" alerts can lead … June 20, 2018 Drawn curtains, muted alarms, and diverted attention lead to tragedy in

  9. The impact of resident duty hour reform on hospital readmission rates among Medicare beneficiaries. | PSNet

    psnet.ahrq.gov/issue/impact-resident-duty-hour-reform-hospital-readmission-rates-among-medicare-beneficiaries
    November 26, 2014 - July 1, 2009 Did duty hour reform lead to better outcomes among the highest risk patients … May 25, 2011 Did duty hour reform lead to better outcomes among the highest risk patients

  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74104/psn-pdf
    November 24, 2021 - examining-meaning-language-used-communicate-nursing-hand During handoffs, nurses are exposed to a variety of interruptions and distractions which may lead

  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72761/psn-pdf
    February 17, 2021 - joint-statement-multiple-patients-ventilator https://psnet.ahrq.gov/issue/drawn-curtains-muted-alarms-and-diverted-attention-lead-tragedy-postanesthesia-care-unit

  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/855002/psn-pdf
    November 01, 2023 - temporarily-holding-medication-orders-safely-order-prevent-patient-harm Process disconnects can cause administration mistakes that lead

  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853971/psn-pdf
    September 27, 2023 - unconscious-bias-among-health-professionals-scoping-review Biases among healthcare professionals can lead

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73885/psn-pdf
    September 29, 2021 - reporting-unsafe-conditions-academic-women-and-childrens-hospital Incident reporting and analysis can lead

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73189/psn-pdf
    April 28, 2021 - suggests that safety initiatives taking a systems-oriented approach and organizational buy- in can lead

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72534/psn-pdf
    December 02, 2020 - patients-perceptions-safety-emergency-medical-services-interview-study Safety problems in prehospital care can lead

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865718/psn-pdf
    May 01, 2024 - calculating-cost-medication-errors-systematic-review-approaches-and-cost- variables Preventable adverse events can lead

  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/855430/psn-pdf
    November 15, 2023 - BMJ Lead. 2023;7(3):196-202. doi:10.1136/leader-2022-000626.

  19. Primary Care and Patient Safety: Opportunities at the Interface | PSNet

    psnet.ahrq.gov/perspective/primary-care-and-patient-safety-opportunities-interface
    September 28, 2022 - AHRQ, as one of the lead federal agencies in primary care research, funds research to understand how … AHRQ is the lead federal agency for patient safety research. … describing 7C’s, 9 9C’s, 10 or even 10C’s. 11 These models all identify functions that ultimately lead … patient values/preferences, and not addressing health inequities attributable to social factors can lead … So, I think we’re well positioned to lead patient safety efforts.

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60745/psn-pdf
    October 01, 2020 - documentation and recording of medications administered or wasted.11 Lack of proper documentation can lead … they believe they are giving the sole dose of the drug.1,11 This error may never be identified or may lead … products should be returned to a secure location.1 Failure to comply with these recommended practices can lead … #5 The lack of a standardized process for wasting of medications in the perioperative setting can lead … the perioperative setting Evaluate controlled substance use processes to identify gaps that could lead
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