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psnet.ahrq.gov/node/42799/psn-pdf
December 04, 2013 - automation can diminish human
performance, decision-making, and situational awareness—and thereby lead
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psnet.ahrq.gov/node/34958/psn-pdf
June 14, 2011 - Faculty of the program used root cause analysis to illustrate
that underlying failures in a system can lead
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psnet.ahrq.gov/node/44436/psn-pdf
October 30, 2017 - https://psnet.ahrq.gov/issue/overreaction
Reporting on how test inaccuracies can lead to misdiagnosis
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psnet.ahrq.gov/node/38931/psn-pdf
April 18, 2011 - around patient safety improvement and professes the intent of the
European Society of Intensive Care to lead
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psnet.ahrq.gov/node/43624/psn-pdf
October 22, 2014 - compendium-strategies-prevent-healthcare-associated-infections-acute-care-hospitals
https://psnet.ahrq.gov/issue/getting-doctors-clean-their-hands-lead-followers
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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(…
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psnet.ahrq.gov/node/43863/psn-pdf
July 16, 2015 - Learning through simulated independent practice leads to
better future performance in a simulated crisis than
learning through simulated supervised practice.
July 16, 2015
Goldberg A, Silverman E, Samuelson S, et al. Learning through simulated independent practice leads to
better future performance in a simulated …
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psnet.ahrq.gov/node/40149/psn-pdf
January 19, 2011 - However, this study found that splitting pills resulted in unpredictable dose deviations, which could
lead
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psnet.ahrq.gov/node/42975/psn-pdf
February 26, 2014 - initiative to standardize concentrations of pediatric oral liquid drugs to
reduce inconsistencies that lead
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psnet.ahrq.gov/node/39683/psn-pdf
June 08, 2011 - of human factors, organizational culture, and
team-based science in surgeons would enable them to lead
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psnet.ahrq.gov/node/35099/psn-pdf
June 09, 2009 - The packaging and
labeling for these medications may be confusing and lead to overdosing.
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psnet.ahrq.gov/web-mm/mistaken-identity
December 18, 2014 - 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.
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psnet.ahrq.gov/node/36813/psn-pdf
March 24, 2011 - Ambulatory care adverse events and preventable adverse
events leading to a hospital admission.
March 24, 2011
Woods D, Thomas EJ, Holl JL, et al. Ambulatory care adverse events and preventable adverse events
leading to a hospital admission. Qual Saf Health Care. 2007;16(2):127-131.
https://psnet.ahrq.gov/issue/amb…
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psnet.ahrq.gov/issue/effects-resident-duty-hour-reform-surgical-and-procedural-patient-safety-indicators-among
November 26, 2014 - November 26, 2014
Did duty hour reform lead to better outcomes among the highest risk … April 6, 2011
Did duty hour reform lead to better outcomes among the highest risk patients
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psnet.ahrq.gov/node/38577/psn-pdf
April 22, 2009 - Leading your organization to high reliability.
April 22, 2009
Kemper C, Boyle DK. Leading your organization to high reliability. Nurs Manag. 2009;40(4):14-18.
doi:10.1097/01.NUMA.0000349684.24165.68.
https://psnet.ahrq.gov/issue/leading-your-organization-high-reliability
This commentary describes high reliability …
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psnet.ahrq.gov/node/43732/psn-pdf
January 07, 2015 - that such
delays are not always due to error, this commentary reviews how diagnostic difficulty can lead
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psnet.ahrq.gov/node/41589/psn-pdf
July 02, 2014 - Prior research has
shown that inappropriate use of heuristics can lead to diagnostic errors.
-
psnet.ahrq.gov/node/44481/psn-pdf
September 09, 2015 - This news article reports on
how misdiagnosis may lead to patient harm, cognitive biases that can contribute
-
psnet.ahrq.gov/node/36140/psn-pdf
September 29, 2010 - Bottles may have been
erroneously filled with another medication, which could lead to serious health