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psnet.ahrq.gov/node/46081/psn-pdf
April 19, 2017 - Why are medical errors still a leading cause of death?
April 19, 2017
Headley M.
https://psnet.ahrq.gov/issue/why-are-medical-errors-still-leading-cause-death
This magazine article explores the need for robust research and effective reporting to better understand the
prevalence of medical errors and how to prevent…
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psnet.ahrq.gov/node/39110/psn-pdf
June 10, 2018 - Order scanning systems may pull multiple pages through
the scanner at the same time, leading to drug omissions.
June 10, 2018
ISMP Medication Safety Alert! Acute Care Edition. November 5, 2009;14:1-3.
https://psnet.ahrq.gov/issue/order-scanning-systems-may-pull-multiple-pages-through-scanner-same-time-
leading-dru…
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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/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/issue/electronic-prescribing-vulnerabilities-height-and-weight-mix-leads-dosing-error
June 10, 2018 - Newspaper/Magazine Article
Electronic prescribing vulnerabilities: height and weight mix-up leads to dosing error.
Citation Text:
Electronic prescribing vulnerabilities: height and weight mix-up leads to dosing error. ISMP Medication Safety Alert! Acute care edition. August 26, 2010;15:1…
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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/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/38498/psn-pdf
September 27, 2016 - a lengthy process, and the large number of
interruptions nurses experience during the process may lead
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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/39559/psn-pdf
December 17, 2010 - understanding of the
dispensing process, and were unable to identify underlying system factors that could 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/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
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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/43095/psn-pdf
April 09, 2014 - This study uncovered potential preparation errors that were
previously unrecognized and could lead to
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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/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/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/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/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/44239/psn-pdf
September 29, 2017 - When medical care leads to harm—difficulty finding
words: a teachable moment.
September 29, 2017
Chamberlain E, DiVeronica M, Segura R. When medical care leads to harm- difficulty finding words: a
teachable moment. JAMA Intern Med. 2015;175(8):1271-1272. doi:10.1001/jamainternmed.2015.2334.
https://psnet.ahrq.gov/…