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  1. 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

  2. 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

  3. 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

  4. 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

  5. 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

  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/46524/psn-pdf
    October 18, 2017 - pressure-injury-prevention-hospitals-training-program Pressure ulcers are a common hospital-acquired condition that can lead

  8. 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

  9. 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

  10. 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

  11. 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

  12. 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

  13. 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

  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38598/psn-pdf
    June 03, 2010 - Leading successful rapid response teams: a multisite implementation evaluation. June 3, 2010 Donaldson N, Shapiro S, Scott M, et al. Leading successful rapid response teams: A multisite implementation evaluation. J Nurs Adm. 2009;39(4):176-81. doi:10.1097/NNA.0b013e31819c9ce9. https://psnet.ahrq.gov/issue/leading-…

  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/844553/psn-pdf
    February 15, 2023 - Mental health conditions leading cause of pregnancy- related deaths. February 15, 2023 Quick Safety. January 16 2023;(67):1-3. https://psnet.ahrq.gov/issue/mental-health-conditions-leading-cause-pregnancy-related-deaths Maternal safety is compromised by a range of social, cognitive, and clinical factors. This arti…

  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45357/psn-pdf
    October 09, 2016 - Leading article: how can I optimise my role as a leader within the surgical team? October 9, 2016 Green B, Mitchell DA, Stevenson P, et al. Leading article: how can I optimise my role as a leader within the surgical team? Br J Oral Maxillofac Surg. 2016;54(8):847-850. doi:10.1016/j.bjoms.2016.05.035. https://psnet…

  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43201/psn-pdf
    May 21, 2014 - New HHS Data Shows Major Strides Made in Patient Safety, Leading to Improved Care and Savings. May 21, 2014 Washington, DC: US Department of Health and Human Services; May 7, 2014. https://psnet.ahrq.gov/issue/new-hhs-data-shows-major-strides-made-patient-safety-leading-improved- care-and-savings Comparing safety…

  18. Leading causes of anesthesia-related liability claims in ambulatory surgery centers. | PSNet

    psnet.ahrq.gov/issue/leading-causes-anesthesia-related-liability-claims-ambulatory-surgery-centers
    December 16, 2020 - Study Leading causes of anesthesia-related liability claims in ambulatory surgery centers. Citation Text: Ranum D, Beverly A, Shapiro FE, et al. Leading causes of anesthesia-related liability claims in ambulatory surgery centers. J Patient Saf. 2021;17(7):513-521. doi:10.1097/pts.0000000…

  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73498/psn-pdf
    July 14, 2021 - Leaving a discontinued FentaNYL infusion attached to the patient leads to a tragic error July 14, 2021 ISMP Medication Safety Alert! Acute care edition. 2021;26(13);1-2. https://psnet.ahrq.gov/issue/leaving-discontinued-fentanyl-infusion-attached-patient-leads-tragic-error High-alert medication misadministration i…

  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46329/psn-pdf
    September 06, 2017 - risk-factors-missed-colorectal-lesions-after-colonoscopy Failure to detect abnormalities during testing can lead
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