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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/74188/psn-pdf
    December 15, 2021 - addition to creating challenges for trainee comprehension of surgical instruction, ambiguous language can lead
  2. 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
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/865977/psn-pdf
    May 29, 2024 - complication-rates-central-venous-catheters-systematic-review-and-meta- analysis The use of central venous catheters (CVC) can lead
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866162/psn-pdf
    June 19, 2024 - surgeon-and-surgical-trainee-experiences-after-adverse-patient-events Adverse events in surgery can lead
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60722/psn-pdf
    February 06, 2023 - 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 … In current circumstances, this cognitive (anchoring) bias may lead clinicians to miss the diagnosis of … Premature closure may also lead clinicians to make a presumptive diagnosis of COVID-19 (allowing the
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854818/psn-pdf
    October 25, 2023 - The nature, causes, and clinical impact of errors in the clinical laboratory testing process leading to diagnostic error: a voluntary incident report analysis. October 25, 2023 van Moll C, Egberts TCG, Wagner C, et al. The nature, causes, and clinical impact of errors in the clinical laboratory testing process lea…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/838222/psn-pdf
    September 28, 2022 - them out to do things they don’t need to do, and avoid unnecessary tests or treatments that might lead … So, I think we’re well positioned to lead patient safety efforts. … I think primary care has an opportunity to lead the patient safety effort or to claim it as part of … We need to lead the charge in making sure that those organizations have the information they need to … Those transitions are important, and I think primary care can lead by example and demand from our
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38938/psn-pdf
    July 26, 2023 - Drug name confusion can easily lead to medication errors, and the ISMP has recommended interventions
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/854982/psn-pdf
    November 01, 2023 - medicine-self-administration-errors-older-adult-population-systematic-review https://psnet.ahrq.gov/issue/polypharmacy-elderly-when-good-drugs-lead-bad-outcomes-teachable-moment
  10. 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.
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73922/psn-pdf
    October 06, 2021 - Leading causes of anesthesia-related liability claims in ambulatory surgery centers. October 6, 2021 Ranum D, Beverly A, Shapiro FE, et al. Leading causes of anesthesia-related liability claims in ambulatory surgery centers. J Patient Saf. 2021;17(7):513-521. doi:10.1097/pts.0000000000000431. https://psnet.ahrq.go…
  12. 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
  13. 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
  14. 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
  15. 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
  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/73189/psn-pdf
    April 28, 2021 - suggests that safety initiatives taking a systems-oriented approach and organizational buy- in can lead
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/851194/psn-pdf
    July 05, 2023 - psnet.ahrq.gov/issue/additional-cost-perioperative-medication-errors Preventable adverse events can lead
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853233/psn-pdf
    September 06, 2023 - weight-estimation-drug-dose-calculations-prehospital-setting-systematic-review Inaccurate estimations of patient weight can lead
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853245/psn-pdf
    September 06, 2023 - intraoperative-communications-between-pathologists-and-surgeons-do-we- understand-each-other Miscommunication between pathologists and surgeons can lead

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