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381. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46441/psn-pdf
     December 06, 2017 - role in diagnosis, and inadequate systems for tracking completion of necessary follow-up studies can lead

382. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39486/psn-pdf
     May 05, 2010 - understanding-handling-drug-safety-alerts-simulation-study This study highlights contributing factors that lead

383. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43864/psn-pdf
     January 28, 2015 - checklists, resources, and implementation guidance to help clinical nurse specialists develop and lead

384. Medical Mistakes and What Doctors Can Learn From Pilots | PSNet
     psnet.ahrq.gov/training-catalog/medical-mistakes-and-what-doctors-can-learn-pilots
     events that discusses strategies to avoid medical mistakes, how to recognize cognitive biases that can lead

385. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41331/psn-pdf
     October 03, 2017 - Leading a highly visible hospital through a serious reportable event. October 3, 2017 Erickson JI. Leading a highly visible hospital through a serious reportable event. J Nurs Adm. 2012;42(3):131-3. doi:10.1097/NNA.0b013e31824808b6. https://psnet.ahrq.gov/issue/leading-highly-visible-hospital-through-serious-repor…

386. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46463/psn-pdf
     October 04, 2017 - Effectively leading for quality. October 4, 2017 Lachman P, Nicklin W. Effectively leading for quality. Healthc Manage Forum. 2017;30(5):233-236. doi:10.1177/0840470417706705. https://psnet.ahrq.gov/issue/effectively-leading-quality Hospital boards and executives can help drive safety improvement. This commentary …

387. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38619/psn-pdf
     May 07, 2018 - Failed check system for chemotherapy leads to pharmacist's "no contest" plea for involuntary manslaughter. May 7, 2018 ISMP Medication Safety Alert! Acute Care Edition. April 23, 2009;14:1-2. https://psnet.ahrq.gov/issue/failed-check-system-chemotherapy-leads-pharmacists-no-contest-plea- involuntary-manslaughter …

388. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38886/psn-pdf
     August 26, 2009 - Medication overdoses leading to emergency department visits among children. August 26, 2009 Schillie SF, Shehab N, Thomas KE, et al. Medication overdoses leading to emergency department visits among children. Am J Prev Med. 2009;37(3):181-7. doi:10.1016/j.amepre.2009.05.018. https://psnet.ahrq.gov/issue/medication…

389. 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.

390. 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

391. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/34785/psn-pdf
     February 18, 2011 - perspective, one that not only raises concern over all currently available novel therapies but also may lead

392. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35348/psn-pdf
     October 26, 2007 - for reporting by explaining the benefits that come from such vigilance and how changing systems can lead

393. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44649/psn-pdf
     November 11, 2015 - psnet.ahrq.gov/issue/seven-potentially-deadly-prescribing-errors Errors in the prescribing process can lead

394. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46443/psn-pdf
     September 27, 2017 - https://psnet.ahrq.gov/issue/overtreatment-united-states Overuse of medical care can lead to patient

395. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46729/psn-pdf
     January 17, 2018 - https://psnet.ahrq.gov/issue/diagnostic-error-pediatric-cancer Missed or delayed cancer diagnoses can lead

396. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42857/psn-pdf
     January 15, 2014 - persistent overuse of routine laboratory tests and underutilization of certain tests (which could lead

397. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46558/psn-pdf
     November 01, 2017 - commentary describes how a project utilized fault-tree analysis as a method to examine elements that lead

398. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40747/psn-pdf
     September 07, 2011 - misdiagnosis-analysis-based-case-record-review-proposals-aimed-improve- diagnostic-processes The various types of cognitive biases that can lead

399. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46800/psn-pdf
     May 16, 2018 - psnet.ahrq.gov/issue/ireland-investigates-cervical-cancer-screening-scandal Large-scale adverse events should lead

400. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/37417/psn-pdf
     March 28, 2012 - Medication use leading to emergency department visits for adverse drug events in older adults. March 28, 2012 Budnitz DS, Shehab N, Kegler SR, et al. Medication use leading to emergency department visits for adverse drug events in older adults. Ann Intern Med. 2007;147(11):755-765. https://psnet.ahrq.gov/issue/med…