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341. 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…

342. 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…

343. 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…

344. 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

345. 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…

346. PSNet Curated Library (pdf file)
     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 …

347. PowerPoint Presentation (ppt file)
     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

348. 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…

349. 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…

350. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35833/psn-pdf
     July 23, 2010 - the literature on medication administration errors and categorize systems and personnel issues that lead

351. Psn-Pdf (pdf file)
     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

352. Psn-Pdf (pdf file)
     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

353. Psn-Pdf (pdf file)
     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

354. Psn-Pdf (pdf file)
     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…

355. Psn-Pdf (pdf file)
     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…

356. Psn-Pdf (pdf file)
     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/…

357. Psn-Pdf (pdf file)
     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

358. Psn-Pdf (pdf file)
     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

359. Psn-Pdf (pdf file)
     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 …

360. Psn-Pdf (pdf file)
     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(…