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461. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45173/psn-pdf
     November 18, 2016 - Prior analyses have suggested that HACs lead to nearly $150 million per year in excess Medicare costs

462. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43250/psn-pdf
     December 01, 2016 - found that children with complex chronic conditions are at higher risk for adverse drug events that lead

463. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35127/psn-pdf
     February 24, 2011 - health care providers represent a critical information source to better understand the systems that lead

464. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44479/psn-pdf
     September 09, 2015 - https://psnet.ahrq.gov/issue/health-literacy-primary-care-practice Limited health literacy can lead

465. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35069/psn-pdf
     June 22, 2009 - towards-organization-memory-exploring-organizational-generation-adverse- events-health-care The authors examine the organizational factors that lead

466. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49845/psn-pdf
     October 01, 2018 - However, the error did lead to the performance of additional blood tests (mostly activated partial thromboplastin … critical medication is unavailable, this case illustrates how a seemingly safe substitution strategy can lead … With heparin, an overdose can lead to a stroke, or even death, especially in vulnerable populations … Just like errors involving heparin, errors involving saline injection can lead to devastating outcomes

467. Leading clinical handover improvement: a change strategy to implement best practices in the acute care setting. | PSNet
     psnet.ahrq.gov/issue/leading-clinical-handover-improvement-change-strategy-implement-best-practices-acute-care
     May 18, 2022 - Commentary Leading clinical handover improvement: a change strategy to implement best practices in the acute care setting. Citation Text: Clarke CM, Persaud DD. Leading Clinical Handover Improvement. J Patient Saf. 2011;7(1):11-18. doi:10.1097/pts.0b013e31820c98a8. Copy Citation …

468. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/35669/psn-pdf
     July 08, 2008 - The authors conclude with a call to action for organizations best positioned to lead this charge, including

469. The absence of a drug–disease interaction alert leads to a child's death. | PSNet
     psnet.ahrq.gov/issue/absence-drug-disease-interaction-alert-leads-childs-death
     July 08, 2015 - July 29, 2020 Drawn curtains, muted alarms, and diverted attention lead to tragedy in

470. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/74089/psn-pdf
     July 15, 2002 - effect-race-and-sex-physicians-recommendations-cardiac-catheterization Gender, racial, and ethnic disparities in healthcare can affect patient safety and lead

471. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44400/psn-pdf
     September 23, 2015 - medication safety, handoffs, human factors, and systems vulnerabilities, all of which are known to lead

472. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/42877/psn-pdf
     January 22, 2014 - identification-poor-performance-national-medical-workforce-over-11-years-observational-study https://psnet.ahrq.gov/issue/which-clinical-errors-lead-referral-uk-paediatricians-national-clinical-assessment-service

473. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/46473/psn-pdf
     December 18, 2017 - diagnostic-errors-impact-educational-intervention-pediatric-primary-care The National Academy of Medicine has emphasized that diagnostic errors lead

474. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47068/psn-pdf
     June 25, 2018 - need-closed-loop-systems-management-abnormal-test-results Failure to follow up abnormal test results can lead

475. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44490/psn-pdf
     September 16, 2015 - medication-timing errors associated with introduction of computerized provider order entry, which can lead

476. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44968/psn-pdf
     January 23, 2017 - financial-incentives-and-mortality-taking-pay-performance-step-too-far Although financial incentives have been widely adopted, they may not lead

477. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38051/psn-pdf
     May 05, 2018 - Misprogramming PCA concentration leads to dosing errors. May 5, 2018 ISMP Medication Safety Alert! Acute Care Edition. August 28, 2008;13:1-3. https://psnet.ahrq.gov/issue/misprogramming-pca-concentration-leads-dosing-errors This article describes dosing errors associated with improper concentration programming of…

478. Hindsight Bias | PSNet
     psnet.ahrq.gov/glossary/hindsight-bias
     September 13, 2021 - Hindsight Bias September 13, 2021 Anonymous (not verified) In a very general sense, hindsight bias relates to the common expression "hindsight is 20/20." This expression captures the tendency for people to regard past events as expected or obvious, even when, in real time, the events perplexed those involved. M…

479. National estimates of insulin-related hypoglycemia and errors leading to emergency department visits and hospitalizations. | PSNet
     psnet.ahrq.gov/issue/national-estimates-insulin-related-hypoglycemia-and-errors-leading-emergency-department
     October 20, 2021 - Study National estimates of insulin-related hypoglycemia and errors leading to emergency department visits and hospitalizations. Citation Text: Geller AI, Shehab N, Lovegrove MC, et al. National estimates of insulin-related hypoglycemia and errors leading to emergency department visits a…

480. Making hospital care safer and better: the structure-process connection leading to adverse events. | PSNet
     psnet.ahrq.gov/issue/making-hospital-care-safer-and-better-structure-process-connection-leading-adverse-events
     November 04, 2020 - Study Making hospital care safer and better: the structure-process connection leading to adverse events. Citation Text: El-Jardali F, Lagacé M. Making hospital care safer and better: the structure-process connection leading to adverse events. Healthc Q. 2005;8(2):40-8. Copy Citation …