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  1. Psn-Pdf (pdf file)

    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
  2. Psn-Pdf (pdf file)

    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
  3. Psn-Pdf (pdf file)

    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.
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34935/psn-pdf
    June 23, 2009 - pitfalls leading to missed diagnoses, including several types of "cognitive shortcuts" that commonly lead
  5. Psn-Pdf (pdf file)

    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…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/34783/psn-pdf
    March 28, 2005 - the organizational factors that produce errors of perception, judgment, and calculation, which can lead
  7. Psn-Pdf (pdf file)

    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
  8. Psn-Pdf (pdf file)

    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
  9. Psn-Pdf (pdf file)

    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
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43740/psn-pdf
    December 10, 2014 - These findings support the widespread concern that problems with electronic health record usability lead
  11. Psn-Pdf (pdf file)

    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
  12. Psn-Pdf (pdf file)

    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
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46167/psn-pdf
    June 07, 2017 - https://psnet.ahrq.gov/issue/identifying-patients-sepsis-hospital-wards Undiagnosed sepsis can lead
  14. Psn-Pdf (pdf file)

    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
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46837/psn-pdf
    March 21, 2018 - drug-shortages-effect-parenteral-nutrition-therapy Shortages of medications and compounding components can lead
  16. Psn-Pdf (pdf file)

    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
  17. Psn-Pdf (pdf file)

    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
  18. Psn-Pdf (pdf file)

    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
  19. Psn-Pdf (pdf file)

    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
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43095/psn-pdf
    April 09, 2014 - This study uncovered potential preparation errors that were previously unrecognized and could lead to

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