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321. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49572/psn-pdf
     October 01, 2008 - In some cases, incorrect identification may lead primarily to provider embarrassment without any patient … On the other hand, many instances of patient identification errors lead to more than embarrassment—such … errors can lead to serious harm or even loss of life. … Patient identification errors occur at least occasionally in virtually every health system, and some lead … Language barriers may lead to misidentification and increase the likelihood of adverse events.

322. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/852284/psn-pdf
     August 09, 2023 - ‘Medical errors are the third leading cause of death’ and other statistics you should question. August 9, 2023 Jaklevic MC. HealthJournalism.org. July 27, 2023. https://psnet.ahrq.gov/issue/medical-errors-are-third-leading-cause-death-and-other-statistics-you-should- question Published rates of medical errors con…

323. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60191/psn-pdf
     April 01, 2020 - Unprofessional Behavior Leads to Complications. April 1, 2020 Unprofessional Behavior Leads to Complications. JN Learning. 2020. https://psnet.ahrq.gov/issue/unprofessional-behavior-leads-complications Disruptive behavior is a recognized deterrent to safe communication, sharing of concerns and teamwork. This educa…

324. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42735/psn-pdf
     November 13, 2013 - healthcare-technology-hazards This article summarizes an annual report that spotlights health technologies that may lead

325. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39146/psn-pdf
     December 02, 2009 - This commentary explains how inaccurately estimating patient weight in the emergency department can lead

326. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37165/psn-pdf
     May 02, 2018 - lack-standard-dosing-methods-contributes-iv-errors This article discusses the myriad dosing methods that can lead

327. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43340/psn-pdf
     July 23, 2014 - do-doctors-understand-test-results This magazine article reports how weaknesses in physician understanding of statistics can lead

328. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36096/psn-pdf
     September 28, 2010 - how-series-errors-led-recurrent-hypoglycemia This case study illustrates how therapeutic duplication can lead

329. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/866521/psn-pdf
     August 14, 2024 - High reliability in a safety net hospital leading to operational excellence. August 14, 2024 Didion L, Whitfield C, Bishop P, et al. High reliability in a safety net hospital leading to operational excellence. J Patient Saf. 2024;20(5):375-380. doi:10.1097/pts.0000000000001236. https://psnet.ahrq.gov/issue/high-re…

330. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/851656/psn-pdf
     July 26, 2023 - Investigation of urology intraoperative events leading to root cause analysis at national VA medical centers. July 26, 2023 Peard LM, Teplitsky S, Annabathula A, et al. Can J Urol. 2023;30(2):11467-11472. https://psnet.ahrq.gov/issue/investigation-urology-intraoperative-events-leading-root-cause-analysis- national…

331. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38937/psn-pdf
     September 23, 2009 - Cascade iatrogenesis: factors leading to the development of adverse events in hospitalized older adults. September 23, 2009 Thornlow D, Anderson RA, Oddone E. Cascade iatrogenesis: factors leading to the development of adverse events in hospitalized older adults. Int J Nurs Stud. 2009;46(11):1528-1535. doi:10.1016…

332. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36799/psn-pdf
     November 28, 2016 - The evolving role of health educators in advancing patient safety: forging partnerships and leading change. November 28, 2016 Mercurio A. The evolving role of health educators in advancing patient safety: forging partnerships and leading change. Health Promot Pract. 2007;8(2):119-27. https://psnet.ahrq.gov/issue/e…

333. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40262/psn-pdf
     March 02, 2011 - Leading clinical handover improvement: a change strategy to implement best practices in the acute care setting. March 2, 2011 Clarke CM, Persaud DD. Leading Clinical Handover Improvement. J Patient Saf. 2011;7(1):11-18. doi:10.1097/pts.0b013e31820c98a8. https://psnet.ahrq.gov/issue/leading-clinical-handover-impro…

334. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38407/psn-pdf
     February 11, 2009 - science-and-economics-improving-clinical-communication This article presents a case scenario focusing on communication breakdowns that lead

335. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39153/psn-pdf
     December 02, 2009 - diagnosis, this news column illustrates how strictly following quality improvement procedures might lead

336. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/60566/psn-pdf
     June 03, 2020 - Fear of Covid-19 leads other patients to decline critical treatment. June 3, 2020 Hafner K. Fear of Covid-19 leads other patients to decline critical treatment. New York Times. 2020;May 25. https://psnet.ahrq.gov/issue/fear-covid-19-leads-other-patients-decline-critical-treatment The uncertainties surrounding cor…

337. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37201/psn-pdf
     October 06, 2011 - Mistaken identity of skin cleansing solution leading to extensive chemical burns in an extremely preterm infant. October 6, 2011 Mannan K, Chow P, Lissauer T, et al. Mistaken identity of skin cleansing solution leading to extensive chemical burns in an extremely preterm infant. Acta Paediatr. 2007;96(10):1536-7. h…

338. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36587/psn-pdf
     January 14, 2011 - authors describe a tissue specimen marking mechanism that helped identify discrepancies that could lead

339. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40242/psn-pdf
     February 23, 2011 - An anesthesiology department leads culture change at a hospital system level to improve quality and patient safety. February 23, 2011 Fleischut PM, Evans AS, Faggiani SL, et al. An anesthesiology department leads culture change at a hospital system level to improve quality and patient safety. Anesthesiol Clin. 201…

340. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34960/psn-pdf
     June 22, 2009 - Making hospital care safer and better: the structure- process connection leading to adverse events. June 22, 2009 El-Jardali F, Lagacé M. Making hospital care safer and better: the structure-process connection leading to adverse events. Healthc Q. 2005;8(2):40-8. https://psnet.ahrq.gov/issue/making-hospital-care-s…