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  1. Psn-Pdf (pdf file)

    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…
  2. Psn-Pdf (pdf file)

    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…
  3. 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
  4. 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
  5. 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…
  6. 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
  7. 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
  8. 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
  9. 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
  10. 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
  11. 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
  12. 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
  13. 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
  14. 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
  15. 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
  16. 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
  17. 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
  18. 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
  19. 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
  20. Psn-Pdf (pdf file)

    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/…

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