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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…
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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…
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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…
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psnet.ahrq.gov/node/36587/psn-pdf
January 14, 2011 - authors describe a tissue specimen marking mechanism that helped identify discrepancies that could
lead
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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…
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psnet.ahrq.gov/print/pdf/node/867659
July 10, 2024 - PSNet
Curated Library
AHRQ: Agency for Healthcare Research and Quality
Rapid Response Systems
Curated Library
Primers
Rapid Response Systems
September, 7 2019
Rapid response teams represent an intuitively simple concept: when a patient demonstrates signs of
imminent clinical deterioration, a team of providers …
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.362_slideshow.ppt
December 01, 2015 - well-intentioned providers diligently respond to repeated false alarms
However, excessive false alarms can lead … monitoring is a 5-electrode configuration
Acquires 6 limb leads (I, II, III, aVR, aVL, aVF) and
1 chest lead … patient and contacted the physician
However, the correct response should have been to search for another lead
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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…
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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…
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psnet.ahrq.gov/node/35833/psn-pdf
July 23, 2010 - the literature on medication administration errors and categorize systems and
personnel issues that lead
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psnet.ahrq.gov/node/42807/psn-pdf
February 17, 2015 - https://psnet.ahrq.gov/issue/mismatched-prescribing-and-pharmacy-templates-parenteral-nutrition-pn-lead-data-entry-errors
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psnet.ahrq.gov/node/40718/psn-pdf
August 31, 2011 - misinformation-medical-literature-what-role-do-error-and-fraud-play
This commentary discusses how research errors, bias, and fraud lead
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psnet.ahrq.gov/node/37851/psn-pdf
June 18, 2008 - identification-and
This article reviews how the complexity of care in the pediatric intensive care unit may lead
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psnet.ahrq.gov/node/50423/psn-pdf
September 04, 2019 - When a vital sign leads a country astray—the opioid
epidemic.
September 4, 2019
Chidgey BA, McGinigle KL, McNaull PP. When a Vital Sign Leads a Country Astray—The Opioid Epidemic.
JAMA Surg. 2019;154(11):987-988. doi:10.1001/jamasurg.2019.2104.
https://psnet.ahrq.gov/issue/when-vital-sign-leads-country-astray-opio…
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psnet.ahrq.gov/node/40070/psn-pdf
December 08, 2010 - Epidural pump programming error leading to inadvertent
10-fold dosing error during epidural labor analgesia with
ropivacaine.
December 8, 2010
Thyen AB, McAllister RK, Councilman LM. Epidural Pump Programming Error Leading to Inadvertent 10-
Fold Dosing Error During Epidural Labor Analgesia With Ropivacaine. J Pat…
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psnet.ahrq.gov/node/37517/psn-pdf
August 25, 2009 - How health care complexity leads to cooperation and
affects the autonomy of health care professionals.
August 25, 2009
Molleman E, Broekhuis M, Stoffels R, et al. How health care complexity leads to cooperation and affects
the autonomy of health care professionals. Health Care Anal. 2008;16(4):329-341. doi:10.1007/…
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psnet.ahrq.gov/node/41060/psn-pdf
September 06, 2013 - flaws-clinical-reasoning-common-cause-diagnostic-error
Through an illustrative case report, this commentary describes how cognitive biases may lead
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psnet.ahrq.gov/node/36960/psn-pdf
September 12, 2011 - profiles-patient-safety-perfect-storm-emergency-department
The authors present a case of delayed diagnosis and discuss the cognitive dispositions that can lead
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psnet.ahrq.gov/node/43075/psn-pdf
August 02, 2015 - National estimates of insulin-related hypoglycemia and
errors leading to emergency department visits and
hospitalizations.
August 2, 2015
Geller AI, Shehab N, Lovegrove MC, et al. National estimates of insulin-related hypoglycemia and errors
leading to emergency department visits and hospitalizations. JAMA Intern …
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psnet.ahrq.gov/node/39521/psn-pdf
May 12, 2010 - Confusion about epinephrine dosing leading to iatrogenic
overdose: a life-threatening problem with a potential
solution.
May 12, 2010
Kanwar M, Irvin CB, Frank JJ, et al. Confusion about epinephrine dosing leading to iatrogenic overdose: a
life-threatening problem with a potential solution. Ann Emerg Med. 2010;55(…