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361. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42799/psn-pdf
     December 04, 2013 - automation can diminish human performance, decision-making, and situational awareness—and thereby lead

362. Psn-Pdf (pdf file)
     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

363. Psn-Pdf (pdf file)
     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

364. Psn-Pdf (pdf file)
     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

365. Psn-Pdf (pdf file)
     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

366. 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 …

367. 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(…

368. Psn-Pdf (pdf file)
     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 …

369. Psn-Pdf (pdf file)
     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

370. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42975/psn-pdf
     February 26, 2014 - initiative to standardize concentrations of pediatric oral liquid drugs to reduce inconsistencies that lead

371. Psn-Pdf (pdf file)
     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

372. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35099/psn-pdf
     June 09, 2009 - The packaging and labeling for these medications may be confusing and lead to overdosing.

373. Mistaken Identity | PSNet
     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.

374. Psn-Pdf (pdf file)
     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…

375. Effects of resident duty hour reform on surgical and procedural patient safety indicators among hospitalized Veterans Health Administration and Medicare patients. | PSNet
     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

376. Psn-Pdf (pdf file)
     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 …

377. Psn-Pdf (pdf file)
     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

378. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41589/psn-pdf
     July 02, 2014 - Prior research has shown that inappropriate use of heuristics can lead to diagnostic errors.

379. Psn-Pdf (pdf file)
     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

380. Psn-Pdf (pdf file)
     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