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psnet.ahrq.gov/node/46701/psn-pdf
December 20, 2017 - psnet.ahrq.gov/issue/polypharmacy
https://psnet.ahrq.gov/issue/polypharmacy-elderly-when-good-drugs-lead-bad-outcomes-teachable-moment
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psnet.ahrq.gov/node/41296/psn-pdf
April 11, 2012 - psnet.ahrq.gov/issue/i-pass-mnemonic-standardize-verbal-handoffs
Poor communication at transitions of care can lead
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psnet.ahrq.gov/node/49632/psn-pdf
July 01, 2011 - as "handoffs," are pervasive.(1) Failures in
these communication processes are common (2,3) and can lead … a long-term treatment relationship
that can be experienced by patients as a significant loss, and lead … This case
demonstrates how information loss can delay a workup and lead to devastating outcomes. … This can lead to
significant variability in acuity and complexity between caseloads.
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psnet.ahrq.gov/node/34935/psn-pdf
June 23, 2009 - pitfalls leading to missed diagnoses, including several types of
"cognitive shortcuts" that commonly lead
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psnet.ahrq.gov/node/60986/psn-pdf
January 01, 2021 - Organisational crisis resource management: leading an
academic department of emergency medicine through the
COVID-19 pandemic.
October 7, 2020
Gavin N, Romney M-LS, Lema PC, et al. Organisational crisis resource management: leading an academic
department of emergency medicine through the COVID-19 pandemic. BMJ Lea…
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psnet.ahrq.gov/node/34783/psn-pdf
March 28, 2005 - the organizational factors that produce errors of perception, judgment, and calculation,
which can lead
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psnet.ahrq.gov/node/40729/psn-pdf
October 04, 2011 - incidents involving anesthesia equipment failure found that the vast majority of incidents
did not lead
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psnet.ahrq.gov/node/43890/psn-pdf
April 22, 2015 - Because lack of timely follow-up can lead to delays in diagnosis, this work
highlights a gap in current
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psnet.ahrq.gov/node/46524/psn-pdf
October 18, 2017 - pressure-injury-prevention-hospitals-training-program
Pressure ulcers are a common hospital-acquired condition that can lead
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psnet.ahrq.gov/node/43740/psn-pdf
December 10, 2014 - These
findings support the widespread concern that problems with electronic health record usability lead
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psnet.ahrq.gov/node/38498/psn-pdf
September 27, 2016 - a lengthy process, and the large number of
interruptions nurses experience during the process may lead
-
psnet.ahrq.gov/node/44070/psn-pdf
September 09, 2015 - communication-vital-signs-emergency-department-handoff-opportunities-
improvement
Incomplete handoffs and poor communication regarding key clinical information may lead
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psnet.ahrq.gov/node/46167/psn-pdf
June 07, 2017 - https://psnet.ahrq.gov/issue/identifying-patients-sepsis-hospital-wards
Undiagnosed sepsis can lead
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psnet.ahrq.gov/node/39559/psn-pdf
December 17, 2010 - understanding of the
dispensing process, and were unable to identify underlying system factors that could lead
-
psnet.ahrq.gov/node/46837/psn-pdf
March 21, 2018 - drug-shortages-effect-parenteral-nutrition-therapy
Shortages of medications and compounding components can lead
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psnet.ahrq.gov/node/34805/psn-pdf
November 07, 2017 - improvement is
quality assurance and that appropriate documentation and measurement of current practices may lead
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psnet.ahrq.gov/node/43789/psn-pdf
August 05, 2015 - https://psnet.ahrq.gov/issue/do-cell-phones-belong-operating-room
Distractions can lead to care and
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psnet.ahrq.gov/node/43700/psn-pdf
November 19, 2014 - appropriate-use-medical-interpreters
Language barriers between patients and providers can contribute to misunderstandings and lead
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psnet.ahrq.gov/node/45923/psn-pdf
April 19, 2017 - huddles-and-debriefings-improving-communication-labor-and-delivery
Labor and delivery units are high-risk environments where one miscommunication can lead
-
psnet.ahrq.gov/node/43095/psn-pdf
April 09, 2014 - This study uncovered potential preparation errors that were
previously unrecognized and could lead to